The decision and the reasoning

Hired to map, not to install

A PE-backed medical group came to us through our capital partner in July 2026. The seat is a fractional COO running a ninety-day operations and efficiency audit across IT, HR, FP&A, marketing and revenue cycle, and writing the roadmap that follows it. The people in the room were the group's co-founders, a CFO who had just arrived, the department heads for IT, HR and marketing, and a fractional CMO hired weeks before we were. Above them sat a sponsor whose clock runs on margin and exit timing, and the group's own stated wish to move people into better work rather than cut them.

The group was assembled by acquisition. Each office arrived with its own tools, its own website, its own vendor contracts and its own doctor-partner, who holds equity and a reasonable resistance to being centralized without proof that centralizing works. None of that is a failure of judgment. Every office's decisions made sense on their own. What was missing was an owner of the whole, and an inventory of what the group actually ran. Neither existed before this engagement.

What the leadership said hurt most was IT vendor sprawl and overspend in a HIPAA-regulated environment, where every extra vendor is another business associate and another set of security settings nobody switched on. Behind that sat the rest of the picture. A data pipeline the finance team called a black box. An outsourced call center billed per call. Payroll partly computed by hand in the offices. HR requests arriving by email with no queue behind them. Insurance verification done by hand even though the practice-management platform ships its own verification module and electronic eligibility checks. Denials handled mostly by resubmitting the claim.

What they needed was not a platform. They needed a map, one owner for the vendor estate, three or four fixes nobody owned, and one decision answered before anything downstream could be scoped.

Why the first ninety days is a map and not a platform

Five things settled the shape of the work.

A group built by acquisition has never seen itself whole. Any system decision made before the map is a guess about a dependency nobody has drawn, and the history here included a platform conversion that had cost $50,000 to $100,000 per office and had not reduced the ongoing IT bill. The map comes first because it is the only thing that makes the next decision cheaper than the last one.

The cheapest money in a sprawl is the money nobody owns. Duplicate tools, security configurations never enabled, vendors paid twice, contracts that renewed themselves. That money comes out of an inventory, not a build, and it comes out inside the first cycle.

The sponsor's clock changes what counts as a result. Margin that shows up in ninety days and holds is worth more at exit than a platform that lands in a year, because the exit multiple rewards margin a buyer can verify. So the audit orders the work by how durable the dollar is. Yield first: underpayments against contracted rates, denials that resubmission never recovers, fee schedules set below allowable, outsourcing contracts that can simply end. Revenue capture second, because every lever there is gated on open appointment capacity. Cost-out last, because labor only reaches the P&L when the client decides where those people go, and this client wants them redeployed.

This is a regulated environment. Nothing Common Ground hosts carries protected health information; the audit reads, it does not write. That rule shaped the tool we built before the contract existed and every recommendation after it.

Scope is locked to audit, analysis, review and recommendation. Any build is a separate statement of work under the same agreement, so the retainer is never billed twice for the same work and no phase starts before the gate in front of it is answered. The client's real fear was never the size of the number; it was whether the engagement would quietly grow. Writing that promise into the contract answered the fear without touching the price.