Two pillars score lowest across every health system I assess. Not technology. Not scheduling infrastructure. Change readiness. Here's what that actually means and why it predicts everything else.
By Dr. Sarah Matt, MD, MBA | March 31, 2026
Two weeks at ViVE and ACHE this year confirmed a pattern I have been watching for three years. Health systems are buying solutions before they have diagnosed the problem. The technology is good. The pilots are succeeding. The implementations are stalling.
This is not a vendor problem. It is not a physician resistance problem. It is an infrastructure problem, and it lives in the part of the budget nobody fights for.
When I audit health systems against the 5-Pillar Access framework, two pillars score lowest with near-statistical consistency: Care Navigation (Pillar 3) and Change Readiness (Pillar 5).
Not technology. Not scheduling infrastructure. Change readiness.
Pillar 5 asks one question: does your organization have the structural capacity to absorb the improvements you are trying to make? Not the appetite. Not the budget line item. The actual infrastructure.
What that looks like in practice: dedicated project management bandwidth that is not shared with three other initiatives. A clinical champion who can give 40 percent of their time to this, not 10 percent stacked on top of a full clinical load. Clear escalation paths when workflows break, rather than a vendor ticket that sits in a queue for two weeks.
Most organizations score a 3 or 4 out of 10 here.
Not because they do not care. Because change management infrastructure is the item that never makes it into the RFP.
You budget for the technology. You budget for implementation. You sometimes budget for training. You almost never budget for the sustained organizational capacity that makes the technology stick six months after go-live.
That gap is the entire reason pilots succeed and health systems do not scale them.
A pilot succeeds because it has infrastructure the rest of your system does not have. Dedicated project management. A clinical champion with protected time. A vendor who treats your pilot as their reference account and assigns their best implementation team to it.
None of that scales when the pilot ends.
When the vendor's team leaves, the project management falls back to whoever has bandwidth, which usually means nobody with real bandwidth. The clinical champion goes back to full clinical load. The escalation path that worked because the vendor was on speed-dial becomes a ticket system with a 48-hour SLA. The same workflow problems that surfaced in Unit 1 surface in Unit 7, but now there is no dedicated team to resolve them before they become a credibility problem.
I call this the Pilot Trap. The technology worked in the pilot because the change infrastructure was temporarily built around it. When the pilot ended, so did the infrastructure.
The fix is not a better vendor. The fix is naming the change management investment as a line item before the contract is signed, not as a post-mortem item after the rollout stalls.
Last month I was rounding at a 600-bed system with their CMO and Chief Digital Officer. Their digital front door metrics were strong. Appointment starts were up 22 percent. Digital registrations were climbing.
Then the CMO walked me to a patient floor.
He showed me a whiteboard in a patient's room. Seventy-one-year-old woman. Diabetes, COPD, heart condition. Five-day inpatient stay. On her whiteboard: four phone numbers she had written herself. Cardiology scheduling. Pulmonary clinic. Endocrinology. The main hospital line.
Nobody had given her a care navigation plan. Nobody had told her the portal she used to check in could also schedule her follow-up appointments. The system had invested in digital patient engagement. The patient had no idea it existed.
That gap, between the technology performing and the patient knowing it exists, is the entire digital health access problem on one whiteboard. It is not a technology failure. The technology worked. It is an architecture failure: a design problem in how the care model connects to the tools the health system bought.
Change readiness is the infrastructure that closes that gap. It is the clinical champion who trains the floor nurses. It is the project manager who follows up in week three, not just week one. It is the escalation pathway that gets a patient a navigation plan before discharge, not a list of phone numbers.
None of that is in the vendor contract. All of it predicts whether the investment produces outcomes.
The problem almost never lives where leadership thinks it does. Systems that score low on Patient Access almost always present with a complaint about their EHR, their scheduling vendor, or their patient portal. The real constraint is almost always upstream: either care navigation or change readiness. The technology is performing. The organizational infrastructure around it is not.
The systems that move fastest separate the diagnostic from the decision. Before selecting a vendor, before designing a pilot, before writing an RFP, they get an honest picture of where their system actually stands across the five dimensions that predict whether anything they buy will actually work. The Access Audit takes 10 minutes. It tells you something three vendor presentations will not.
Pilot success is not the same as scale success. A pilot succeeds because it has dedicated infrastructure that does not exist in the rest of the organization. None of that scales. Nobody tells you that going in. The organizations that break the Pilot Trap are the ones that name the change management investment before the contract, not after the rollout stalls.
If your Access Audit scores are pointing at Pillar 5, or if your last implementation stalled in ways that match the pattern above, that is the diagnostic conversation worth having.
I have kept a small number of engagements open through April. The conversation starts at calendly.com/sarahmattmd.
If you want the framework in writing before that conversation, the Pilotitis Playbook maps all five pillars, with a 90-minute team assessment your steering committee can run before the next technology decision.
Strategy, governance, and clinical operations. No hype. No recap journalism. Just the practitioner's read.
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