Leadership in Flow | Harun Rabbani, Precilium
Last year, the regulatory submission went out late. Not because the science was weak. Not because the team lacked experience. But because three people believed they had authority over the final sign-off, and by the time that ambiguity was resolved, the window had narrowed.
This year, the same organisation hired a stronger Head of Regulatory Affairs. The decisions are still slow and that’s the paradox.
The Signal
Important decisions are being revisited more frequently, despite leadership teams that are objectively more capable than they were twelve months ago.
This is not a hypothesis. It is a pattern that shows up, with remarkable consistency, across scale-stage MedTech and HealthTech organisations at a specific inflection point in their growth. The leadership team is stronger. The CVs are more impressive. The CEO has invested significantly in talent and structure. And yet resolution is delayed. Alignment, once achieved, proves temporary. The same questions surface in different forums. Senior leaders find themselves relitigating issues they believed were closed.
The instinct, almost universally, is to assume that something is wrong with the people. But that instinct, in itself, is wrong. In MedTech specifically, the consequences are not merely frustrating but are in actuality measurable.
Clinical and commercial teams operating to different timelines create submission delays. Product, quality, and engineering functions escalate decisions that should be resolved at function level, consuming executive bandwidth that should be focused elsewhere.
NHS procurement opportunities stall because it is not clear, internally, who owns the decision to move. The organisation remains compliant. It simply cannot move at the speed the market requires.
At Precilium we describe these patterns as Signal Before Scale™ indicators: observable changes in organisational behaviour that emerge before performance metrics deteriorate.
For boards and investors, this matters because decision debt often becomes visible long before revenue slows, milestones slip, or key talent leaves. It is a leading indicator of execution risk, not a lagging symptom of it. And like most leading indicators, it is most actionable precisely when it is least obvious.
The signal is observable. The cause is structural. And it almost always precedes the loss of momentum that boards and investors notice later.
Why Intelligent Leaders Miss It
The frustrating truth is that most of the responses to this signal make it worse.
When decisions slow down, the natural instinct is to add visibility: more reporting, more meetings, more sign-off layers. This feels like control but it is not. Reporting creates the feeling of progress. Clear decision rights create actual progress. The two are easily confused, and in regulated environments where governance expectations are high, the confusion is particularly costly.
It is the organisational equivalent of adding more lanes to a congested motorway. The traffic does not move faster. There is simply more of it.
Organisations also normalise slowness, because it arrives gradually. The first time a cross-functional decision takes three weeks instead of one, someone explains it as a busy period. The second time, it becomes the new normal. By the time it is recognised as a pattern, the organisation has restructured itself around the delay. How? By adding governance layers, pre-approval meetings, and reporting rituals that codify the problem rather than resolve it.
There is a further complication. Organisations that have invested heavily in talented people (as most scale-stage MedTech companies have) find it particularly difficult to question the decision architecture. The investment in people is visible and emotionally significant. The architecture is invisible and hard to name. When execution slows, it feels more natural to add another resource than to redesign the system through which existing resources operate.
The paradox is precise. The more you invest in capable people without updating the architecture through which they work, the more friction you create. Experience without structural clarity does not accelerate decisions. It multiplies the number of people with a credible claim to make them.
Harvard Business Review research by Paul Rogers and Marcia Blenko examined this dynamic directly, noting that in many organisations decisions “routinely get stuck inside the organisation like loose change.” Their study of decision-making across hundreds of global companies found that ambiguity over who is accountable for which decisions (not individual capability) was the primary driver of decision stall. In one manufacturer, two functions each believed they were responsible for key product decisions. The result was “endless revisiting of decisions and missed deadlines that led to lost sales.” [4]
This pattern is as familiar in regulated healthcare environments as anywhere else. The forum changes. The underlying dynamic does not.
The Hidden Cost of Decision Debt
There is a useful analogy here to technical debt in software engineering. Organisations accumulate what might be called decision debt: a backlog of unresolved, partially resolved, or revisited decisions that quietly consume leadership time and erode execution confidence.
Decision debt does not announce itself. It accumulates almost politely. The board asks for an update on something resolved three months ago. A commercial decision requires sign-off from four functions that have slightly different understandings of their authority. A resource allocation that should be routine escalates to the CEO because two leaders cannot determine, without that escalation, whose call it is.
Each of these incidents, taken individually, seems manageable. Collectively, they represent something more serious: the early stages of execution coherence loss.
McKinsey research involving more than 1,200 managers across global companies found widespread frustration with decision-making processes specifically with their pace and quality. Fewer than half of executives surveyed agreed that their organisations made decisions quickly; only 37 per cent reported that decisions in their organisation were both high quality and fast. [1] These are not organisations staffed by the mediocre. They are organisations whose structural design has not kept pace with their human capability.
McKinsey’s 2023 State of Organisations report drawing on more than 2,500 senior leaders across eight countries found that two-thirds of respondents viewed their organisations as overly complex and inefficient. [2] In MedTech and HealthTech, where regulatory windows are fixed, clinical timelines are unforgiving, and the cost of a delayed market entry compounds quarterly, that is not an operational inconvenience. It is a commercial risk that belongs on the board agenda.
The hidden costs run further than most leaders appreciate. Every decision that circulates without resolution consumes not just time but attention. Senior leaders begin to pre-empt escalation by attending more meetings, adding reporting layers, and centralising decisions that were previously delegated. These are rational responses to immediate frustration. They are, simultaneously, precisely the actions that compound the underlying problem.
McKinsey documented this cycle directly, citing a Fortune 100 CEO who centralised decision-making during a period of financial difficulty. The outcome was better cost control but significantly slower execution. Several major opportunities were missed because the organisation could not move quickly enough. Decentralisation had to be reinstated. [3]
The lesson is not that centralisation is always wrong. The lesson is that organisations under pressure reach for structural responses that feel safe, and that the costs of doing so are rarely visible until the window for course correction has already narrowed.
A Case Study in Structural Lag
Philips provides a useful illustration, operating at conglomerate scale but exhibiting dynamics familiar to any health technology organisation that has outgrown its architecture.
Through the 2000s, Philips accumulated significant leadership capability and technical expertise. What it had not updated was the architecture through which decisions were made. The signal was not catastrophic failure but was accumulated drag: low empowerment in customer-facing roles, insufficient decision authority in market leadership teams, and a persistent disconnect between commercial and operational functions. [3a]
When Frans van Houten became CEO in 2011, the transformation required was not primarily a talent transformation. It was structural: redefining end-to-end decision accountability, clarifying how authority moved from product development through to commercial execution.
The talent had been present for years. The architecture through which that talent could act coherently had not kept pace. Rebuilding it took a decade.
The lesson is direct. Structural lag is not visible until its consequences are. By the time the consequences are visible, the recovery is expensive.
What Leadership Architecture Actually Means
Leadership capability and leadership architecture are not the same thing.
Capability refers to what individual leaders can do: experience, judgement, functional expertise, strategic acuity. Organisations rightly invest substantially in building it.
Architecture refers to the system through which that capability is expressed collectively. It encompasses the clarity of decision rights, the structure of accountability, the design of escalation pathways, and the degree to which authority is synchronised with responsibility across the organisation.
Most scale-stage organisations invest heavily in the former and allow the latter to accumulate by accident. Decision rights drift. Accountability frameworks become implicit rather than explicit. Leaders who are individually excellent begin to operate in a system that is subtly misaligned, and the organisation starts to experience consequences it cannot easily name.
In a MedTech context, this misalignment tends to appear first at the boundaries between functions: between clinical and commercial, between quality and product development, between regulatory affairs and market access.
These are precisely the boundaries where decisions carry the greatest commercial consequence and where authority is most frequently ambiguous. They are also the boundaries where patient safety and compliance considerations add further complexity to decisions that are already structurally unclear.
The absence of architectural clarity does not prevent decisions from being made. It ensures that they are made more slowly, at higher levels of the organisation than necessary, and with a higher probability of being revisited.
Six Diagnostic Questions
These are not assessment criteria but more like thinking instruments. The value is not in answering them definitively but in examining where consensus proves elusive.
1. When a significant decision stalls in your organisation, what is the most common stated reason?
The language leaders use to explain delay is itself a signal. “We need more data” can mean the decision is genuinely uncertain, or it can mean no one is clear on whose call it is.
2. How many people are typically involved in resolving a decision that sits at the intersection of two functions?
Cross-functional decisions (clinical and commercial, quality and product, regulatory and market access) are the most reliable indicator of architectural alignment. If they consistently require more people than the decision rationally warrants, the architecture is not doing its job.
3. Is the authority to make a given decision clearly documented, or is it understood informally?
Informal understanding works well in smaller organisations where shared context is dense. As organisations scale, it can quietly become a source of decision debt. New leaders arrive with a clear view of what they own, only to discover that others hold a different interpretation. What once felt obvious becomes contested, slowing decisions and increasing friction.
4. How often are decisions made at a given level of the organisation subsequently revisited at a higher level?
One of the earliest signs of decision debt is systematic revisitation. Decisions that appear settled find their way back onto agendas, into meetings, or up escalation pathways. This is not primarily a judgement on people. It is a signal that the underlying decision architecture requires attention.
5. Does your leadership team have a shared, explicit vocabulary for describing where a decision sits in the organisation?
The absence of a common language for decision authority is consistently underestimated as a source of coordination friction. Without shared vocabulary, alignment is informal, fragile, and difficult to sustain across a growing team or a multi-entity portfolio.
6. Which decisions depend disproportionately on a single individual?
Concentrated decision dependency is one of the earliest signals of leadership architecture under strain. When a CEO, Chief Medical Officer, or Regulatory leader becomes the de facto resolution point for decisions that should be distributed, the organisation is relying on people to compensate for structure. That often works for a while. Until growth increases complexity. Until the volume of decisions exceeds individual capacity. Until a key leader becomes unavailable. What looked like strong leadership is revealed to be a hidden bottleneck.
What to Do With the Signal
A point of intellectual honesty is warranted.
The relationship between organisational scale and decision-making friction is well established. Across sectors, larger and more complex organisations tend to experience greater coordination overhead, less clarity of ownership, and slower decision velocity.
The challenge lies not in recognising the pattern, but in diagnosing the cause. While the symptoms may be similar, the underlying source of friction is often organisation-specific.
What appears to be a capability issue may in fact be a governance issue. What looks like a governance problem may be a decision-rights problem. What seems to be a structural challenge may ultimately be a leadership challenge. Effective diagnosis requires distinguishing the symptom from the source.
The signal in this article is observable and commercially relevant precisely because it precedes visible loss of momentum. By the time execution slowdown is apparent to investors and boards, the structural adjustment required is significantly larger, more disruptive, and more expensive than it would have been earlier.
The instinct to hire more, to report more frequently, to add governance structures, is understandable. But it is an instinct shaped by familiarity rather than diagnosis.
Better teams do not automatically create faster decisions. Leadership architecture determines whether capability translates into momentum.
Execution loses coherence before organisations lose momentum. By the time momentum is visibly lost, the opportunity for simple correction has often passed.
The numbers tell us where we’ve been. The signals tell us where we’re going.
Sources
[1] “Decision Making in the Age of Urgency.” McKinsey & Company, April 2019. https://www.mckinsey.com/capabilities/people-and-organizational-performance/our-insights/decision-making-in-the-age-of-urgency
Note: Research surveyed executives across global organisations. Figures cited (fewer than half agreeing their organisations made decisions quickly; 37 per cent reporting high quality and speed) are drawn directly from survey findings. Research does not disaggregate by sector; MedTech and HealthTech implications represent the author’s interpretation applied to regulated-industry context.
[2] “The State of Organizations 2023: Ten Shifts Transforming Organizations.” McKinsey & Company, April 2023. https://www.mckinsey.com/capabilities/people-and-organizational-performance/our-insights/the-state-of-organizations-2023
Note: Survey covered more than 2,500 business leaders in organisations with at least 1,000 employees across eight countries. The two-thirds figure refers to self-reported perception that organisations are “overly complex and inefficient.” This is perception data; it should be read as indicative of widespread organisational experience rather than objective measurement.
[3] “Untangling Your Organization’s Decision Making.” McKinsey & Company, June 2017. https://www.mckinsey.com/capabilities/people-and-organizational-performance/our-insights/untangling-your-organizations-decision-making
[3a] “The Strategic Transformation of Royal Philips.” London Business School / Harvard Business Review Store, case study LBS338. https://store.hbr.org/product/the-strategic-transformation-of-royal-philips/LBS338
Note: The Philips case is drawn from an LBS case study co-authored by a former Philips executive board member, based on direct experience and internal interviews. It represents a single longitudinal case and should not be read as universally generalisable without further corroboration.
[4] “Who Has the D? How Clear Decision Roles Enhance Organizational Performance.” Paul Rogers and Marcia Blenko, Harvard Business Review, January 2006. https://hbr.org/2006/01/who-has-the-d-how-clear-decision-roles-enhance-organizational-performance
Note: Study drew on research across 350 global companies examining organisational effectiveness and decision-making. The structural dynamics identified are consistent with more recent McKinsey findings. Research predates the current MedTech scale environment; the principle of decision-rights clarity applies across regulated sectors.
Harun Rabbani is founder of Precilium and host of Signal Before Scale™ Conversations, where he explores the leadership and execution signals that shape MedTech organisations as they grow.
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