Joey Wahler (Host): He's written about it in his article titled "Margin, Morale, and Medicine" in the July and August 2026 issue of Healthcare Executive magazine. So, we're discussing how clinical governance can align purpose and performance in large health systems. Our guest is indeed Dr. Vimal Ramjee. He's physician executive and cardiologist with CommonSpirit Health.

This is the Healthcare Executive podcast from the American College of Healthcare Executives, providing you with insightful commentary and developments in the world of healthcare leadership. To learn more, please visit ache.org. And a reminder, you don't need more tools, you need results. Med-Metrix helps health systems deliver solutions that turn revenue cycle management into predictable yield end to end or where you need it most. Find out how at med-metrics.com. Thanks so much for joining us. I'm Joey Wahler. Hi there, doctor. Welcome

Vimal Ramjee, MD, FACHE: Hi Joey, thank you for having me.

Host: Great to have you aboard. We appreciate the time. So first, what would you say most motivated you initially to become involved in healthcare and particularly as a physician?

Vimal Ramjee, MD, FACHE: My path in healthcare really started with a passion for science and research, I think like many of my peers and clinical leaders listening. But I would tell you that probably the big inflection point for me was around sophomore, junior year of college. I was a student at Emory University, and I had the opportunity to volunteer in the student outreach program at Grady Hospital in Atlanta.

Grady is one of the most well-known safety net hospitals in the country and the largest in Georgia, with a majority of patients who are vulnerable, underserved, uninsured. And so as a college student, that was a formative experience for me. I had the opportunity to go to Grady, and I remember quite vividly volunteering in the emergency room.

There was a blue zone for medical emergencies and a red zone for trauma. As a student, never having been directly exposed to healthcare before, I remember vividly my first night there seeing the halls lined with people who were suffering from trauma, car accidents, gunshot wounds, and a number of other chronic and acute care problems.

I think that was a very important inflection point in my life. It really solidified the idea of serving others and that there was a tremendous need to bring care excellence and systems that function well to communities in need. And so from there, I really discovered my desire, I think, and it sparked my interest in serving a greater purpose to help people in their most vulnerable moments.

And that purpose really hasn't changed. It's been the underlying theme of my career and the focus of what I do, whether it's in cardiology, taking care of people at the bedside, or in programmatic work, doing national governance work in CommonSpirit, or even regional operational work. So, that's really how I found myself connecting my original passion for science and research to the bedside and taking care of patients.

Host: And in fact, so often it seems speaking to people in the industry like yourself, it is those early real-life experiences that help shape where you're going to go in healthcare. So, we alluded to it at the top. In your healthcare executive article, you make a strong case for embedding clinical expertise into enterprise decision-making, particularly in large multi-region health systems.

So in a nutshell, what are the benefits of that, both for the organization and naturally, of course, for patients?

Vimal Ramjee, MD, FACHE: Absolutely. Strong clinical governance is precisely how organizations, whether large but also small and medium, can connect purpose to their performance. And I've seen it time and time again. When you talk about clinical governance, as I refer to it in this article, but also in our work that we do day to day, it's really about allowing the signals from the frontline clinical staff be heard at a higher altitude.

And those signals are incredible. They bring to light moments when care falls short, inefficiencies, and opportunities for improvement. And I call that collectively this—I refer to it as institutional intelligence because it's such a critical aspect of what guides care delivery and health systems, whether they're small, medium, or large.

And so, I think when systems are able to really integrate or embed clinical expertise into decision-making, in essence, what we're doing is creating a data loop. You're able to get those signals and then act upon them. It functions in many ways when it's done well as a low latency data loop.

And what it does is it creates a learning and responsive health system, a system that's not waiting three months or six months or nine months for these metrics on dashboards to change, but rather is integrating some of those clinical signals from the frontline, from the care delivery aspects right into some of the governing decisions and strategic decisions for the organization.

And what results is incredible. I mean, the benefits are tremendous. You then achieve care excellence, reduced variation, better capital allocation, more aligned strategic decisions, and so forth. And so, the outcome is tremendous, and really what comes from it is that you've got care that's designed by people who are delivering it, which is really the best case scenario.

Host: And so, what would you say keeps organizations in some cases from doing that or doing a better job with it?

Vimal Ramjee, MD, FACHE: I think it really depends on the system. There's probably a lot of nuance for every system. And, there are many challenges that we're all facing. But in that context, I would say there's probably a few common themes that I've observed.

One would be legacy structures. I think the organizational chart and how health systems have functioned and structured their governance lanes is not necessarily reflective of where things are today. And in that way, there's a tremendous opportunity for us to think intentionally, thoughtfully, and to step back and ask, "Is this the right structure for now for our vision for the future?" And a big part of that is about moving forward from a place of doing things in silos, you know, operational functions very distinct from strategic functions, which are very distinct from clinical and so forth.

I do not think that that's the path for success. And high-performing health systems have picked up on that and are truly pushing forward on the idea of interdisciplinary whole health system work, where you really have cross-functionality between these different initiatives. And so, I think, that's probably the big theme that I see here.

The other part is physicians and clinical leaders must be invited to shape the governing decisions rather than react to them, and that's a critical part of integrating clinical expertise into the decision-making in a material way.

Host: Organizations often treat clinical governance as a support function for financial strategy rather than as a driver of things. So, what's the cost of that approach, be it financial or otherwise, would you say?

Vimal Ramjee, MD, FACHE: Clinical governance should not be treated as a support function for financial strategy. And I think the big argument that I make or point that I try to make in this article is that clinical governance, when done with intention, rigor, and discipline, is the most robust financial strategy for systems today.

And so, the cost of not doing that, the cost of not embedding and integrating frontline clinical signals into the fiber and the structure of an organization, is that you get lower quality care, you get greater clinical variation. Workforce becomes disengaged because there's a loss of shared purpose and, as a result of all of that, financial underperformance.

In essence, what's happening is you're separating this moral center of care delivery from enterprise strategy, which is not a successful strategy. And I've seen high performance health systems really thrive when they treat those as one and the same. Care delivery and financial performance really are the same work.

Host: Now, in the same article that we're discussing, you open with the story of someone named Grace, which is both powerful and personal. So, tell us about that. What made you start there?

Vimal Ramjee, MD, FACHE: Grace is a tremendously strong young woman who had an unusual story of years of no answers for life-limiting shortness of breath. And we were able to diagnose her ultimately using gold standard evidence-based care and got her back to her full livelihood.

Reason I started with Grace is because, well, I mean, healthcare begins and ends with people. And so, this is not necessarily just about hope and healing, which is what we aspire for. But it's also about bringing compassion, empathy, dignity, particularly in those moments when perhaps efforts are futile or condition is terminal. Bringing that human presence into the bedside is really what defines healthcare, and that's why I started with Grace.

I think now more than ever, we all know that there are tremendous challenges in healthcare. You know, we have inflationary costs and narrow margin environments, a lot of dynamic changes. I would say that more than ever in this kind of climate, clinical leadership, clinical governance being integrated and really staying anchored to our purpose is the antidote really to these challenges and can be protective of systems because it keeps us grounded in the work that's most important, which is the care that we deliver

Host: And speaking of leadership, you led me perfectly into my next question, doctor. Namely, you write as well that cultivating clinical leaders is essentially a retention margin and mission strategy. So in terms of practice, what does that actually look like?

Vimal Ramjee, MD, FACHE: I think back to medical school, which was too long ago, time flies, but ingrained in every physician is the Hippocratic Oath. And that's all to say that clinical leaders, not only physicians, nurses, all the frontline staff, are genuinely and truly moved by the opportunity to make a real difference in the lives of others.

This is why we do what we do. And so, I think that when you step back and realize that and understand that when their agency is respected and real and heard, then that really is something that energizes staff to start to own a lot of the initiatives. And when you have clinical staff, frontline staff owning initiatives, then you have a tremendous increase in engagement, which then results in further retention and ultimately translates to sustainable programs, service lines, and systems that are margin positive.

And so, this really comes back down to the fundamental of we're all here in service of a greater purpose, and that's a shared purpose, but it has to be authentic and real in how we govern that and treat that in health systems today to really manifest the value that we all talk about.

Host: Absolutely. Now, you also frame physician insight as a form of, to use your great phrase that you mentioned earlier, institutional intelligence. So, how can organizations actually capture and use that best?

Vimal Ramjee, MD, FACHE: You know, institutional intelligence refers to the idea of bringing those frontline signals from care providers, whether it's something that's not working well on the floor in the ICU or a scanner that's not functioning optimally or a workflow that needs to be modified.

Those frontline signals are critical data, and they don't show up in dashboards and spreadsheets until months later, which are lagging indicators. And so, I think that being able to reduce the distance between those frontline clinical staff and the decision-makers and the rooms where decisions are made is a key part of capturing this institutional intelligence.

Organizational structures, those legacy structures, as much as they're needed, obviously every system needs to have an organizational structure and chart. But sometimes unintentionally, these structures create barriers to communication. And so, I think a lot of this comes down to cultivating opportunities for meaningful collaboration that's interdisciplinary and involves people from all different teams.

And so, you really cross-pollinate knowledge. And what we've found in doing our market, regional and national work is that some of the best ideas and initiatives have come from those interdisciplinary conversations where you have people who have completely different perspectives bringing their input to an effort together. And so, I think that's definitely something to think about.

The other aspect of this is moving some of the clinical expertise upstream in consequential decisions. And that's really important because it creates an environment where frontline staff are not necessarily reacting to decisions, but rather have become part of those decisions. And this gets back to the idea of agency and having that agency respected, having it be real, and having it heard, because that's really what translates into that intelligence that then changes strategy and decisions for the system.

Host: Now, to many people, as you know, innovation often means technology acquisition, but innovation doesn't, of course, necessarily have to mean technology. So at a time of rapid AI adoption, how can stronger clinical governance ensure that organizations make that important distinction between those two?

Vimal Ramjee, MD, FACHE: Gosh, I mean, you know, as you know, Joey, we're in a real exciting time right now. It's a really a digital era. There's been a tremendous explosion in FDA-authorized AI medical devices. I think we're north of 1400 at this point. And this itself represents an expansive digital capability and potential.

What I worry about in this context is that increasingly I observe technology acquisition and AI to be conflated with the idea of innovation. And that is not at all the case. Innovation at its foundation represents the ability to deliver care more efficiently, effectively, and often with less capital intensity.

I'll give you one example. We have a phenomenal nurse that about six, seven years ago, we reskilled to become a coordinator for an aortic program. An aortic aneurysm is a lethal condition that needs to be observed or surveillanced over a person's lifetime. And if it reaches surgical thresholds, they are referred to a surgeon. At which point in time, they may be taken to surgery if that's clinically appropriate.

And so, we had the opportunity to use technology to build this program. But using the clinical assets and infrastructure that exists already allowed us to build a nurse-led surveillance program that has grown from zero patients when we started it, of course, to now more than three and a half thousand patients.

And in totality, we've replicated that model so that the whole care model under one nurse with no additional capital outlay is taking care of nearly 10,000 people in our community and region. To me, that's transformative. And in a narrow margin environment, I would say that we need to be intentional and bring discipline to innovation and to care redesign, because this is really where there are many opportunities in improving inefficiencies and workflow constraints.

And so, technology certainly, don't get me wrong, can deliver asymmetric gains, and we've done that as well. We've been blessed to build one of the largest deep learning coronary artery disease centers in the nation, and we've had a wonderful experience in learning how to use that technology responsibly and to be good stewards of that technology.

But I would say that the biggest lesson I've seen and learned is that before you reach for technology and digital capability, introspect, and look at where there are workflow inefficiencies and care constraints that can be fixed today that don't cost additional money, particularly in this climate. And that really positions systems and service lines to thrive when they bring technology into their hands because they only generally deliver more value when you have well-working underlying fundamental workflows.

Host: A few other questions for you, doctor. First, for a CEO that's joining us right now as we speak, how about one tangible way to bring clinical judgment closer into enterprise decision-making?

Vimal Ramjee, MD, FACHE: Clinical leaders absolutely need to be present where strategic decisions are shaped and not afterwards. And I think that simply means in action is to involve them earlier and in a more authentic way in truly determining what the strategy is going to be. Often I've observed that it's a decision that's already made and clinical staff are asked to receive that decision and to go with it and react to it.

At that stage, that clinical intelligence and judgment that is such a rich resource, that institutional intelligence that you and I talked about, is a completely missed opportunity. And so, I think bringing clinical leaders into those decision-making rooms earlier and involving them more closely with transparent communication.

Host: Switching gears, Doctor, to your own professional journey. You talked a little bit about it earlier, but how has your career evolved into leadership roles while continuing that passionate work of caring for patients?

Vimal Ramjee, MD, FACHE: When I think about my leadership journey, honestly, it's really less about me and has truly been more about the incredibly talented people around me that I have the privilege of working with, learning from, and advancing our mission with. And so, what I've observed and learned in my journey is that it's a lot less about the title or the role and much more about the impact and the work being done.

In fact, you know, some of the most impressive leaders that I've worked with have been able to drive tremendous positive influence and impact in the organization without a title that fits into an org chart. And what that tells me is that leadership, at the end of the day, is, you know, these are people who have cultivated incredible amounts of relational capital because they're mission-focused. They really are there to do the important work that needs to get done in taking care of the people and the communities and, in general, society. And so for me, that's really been my North Star, and patient care has been the center of my journey.

I would say that, you know, in clinical practice, which I'm blessed to be a practicing cardiologist and to take care of people with a variety of heart conditions and vascular conditions on a patient level. But having had unique experience building food intelligence on the industry side that's now part of Aura, as well as doing work in a governance capability with the American Heart Association, I've seen the impact at a societal level where we've touched tens of thousands, if not hundreds of thousands of lives.

And so, I've really enjoyed that broader impact. And CommonSpirit's doing tremendous work as well across the country. I've had the privilege of being able to serve in a national governance role, helping to form the charter for part of the initiatives for the cardiovascular service line, as well as guiding the system on cardiovascular technology and innovation.

Now, my focus is primarily more recently on regional operations for the South, looking at how we can improve things like length of stay, patient experience in the ED. One example right now that we're working on is using, CT angiography, coronary CT angiography for people who come to the emergency room with chest pain, which is one of the most, if not the most common complaint that presents to the emergency room. And so, how do we make that experience better with better diagnostic accuracy, a lower length of stay, and not holding up capacity in beds and keeping access at the top of our mind as well for the communities that we serve?

And so, at the end of the day, patient care is the center of my leadership journey, and I really have always thought of it as, we need to be stewards of three scarce resources: trust, talent, the amazing people around us, and finally, resources or capital, being good stewards of those things.

Host: And in summary here, Doctor, we ask this to all our guests who are fellows of ACHE, how has that FACHE credential helped to advance in your career, and how would you say it supports clinical leaders overall?

Vimal Ramjee, MD, FACHE: I would say that, to me, it's really an extension of the people aspect. I have been incredibly impressed with just the vibrance and the charisma and the openness of the community at ACHE. Attending Congress is always a joy where you learn so much. But as a physician, the most impactful thing that stands out to me about ACHE is the differentiated exposure to other disciplines.

You know, we don't know what we don't know. And so, I often find that the greatest opportunities where I learn the most are in speaking with strategy, operations, executive leaders who are perhaps not as clinically focused and exchanging with them my perspectives. And so, ACHE has provided a natural forum with other like-minded leaders where I've just tremendously enjoyed it. What I really appreciate is everybody's openness to collaborate, to learn, and to do this work together, particularly during these changing times.

Host: Well, folks, we trust you're now more familiar with clinical governance. Dr. Ramjee, congratulations on your wonderful career to this point. Keep up all your great work, both with patients and leadership and otherwise, and thanks so much again for the time.

Vimal Ramjee, MD, FACHE: Thank you for having me, Joey. It was a pleasure.

Host: Absolutely. Same here indeed. And for more information, please do visit healthcareexecutive.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks so much again for being part of the Healthcare Executive podcast from the American College of Healthcare Executives.