Findings in this brief are drawn from two decades of fieldwork and data analysis, working alongside hundreds of multi-site healthcare organizations and watching their operating models evolve through every stage of this arc.
What this brief argues, in seven lines.
- 01ABA is in a sustained growth cycle: rising prevalence, new payer access, de novo expansion into new metros, and a steady drumbeat of tuck-in acquisitions[1]. Operations organizations are scaling faster than their operating models.
- 02Day-to-day care delivery, scheduling, session notes, billing, intake-to-auth, runs in dedicated practice management and EHR systems. This brief is about the layer around that: the cross-functional initiatives, programs, and integrations that change the business.
- 03The challenges at that layer change in kind, not only in volume, at four inflection points as the footprint grows from 10 to 500+ clinics.
- 04The expensive failure mode at every tier is the same. Initiatives get done, but they do not land consistently across regions, on time, in compliance, with auditable trails.
- 05The capabilities that solve those failures (single-source initiative intake, templated playbooks for openings and integrations, cross-team visibility, credentialing-and-licensure programs, structured policy review, capacity planning, and roll-up reporting) are the core surface area of modern project management platforms.
- 06COOs and VPs of Operations who install this layer before tier 3 reclaim roughly a quarter to a quarter and a half of leadership capacity, and reduce the risk in the next phase of growth.
- 07Use the tier-by-tier framework to locate your organization, the interactive explorer to see the challenges and fixes at your stage, and the self-audit to benchmark your operating maturity against peers at your size.
ABA is growing faster than its operating layer can keep up.
CDC autism prevalence has climbed to 1 in 31 children[3] and demand keeps outpacing capacity. Multi-site groups are expanding on every front at once: de novo openings, new payer contracts, new service lines, and the occasional tuck-in acquisition[1]. Organizations that were 30 clinics three years ago are 120 clinics today. The operating layer that worked at 30 is the source of most of the pain at 120.
A note on scope. Day-to-day care delivery, scheduling, session notes, treatment plans, billing, intake-to-auth, runs in dedicated practice management and EHR platforms (CentralReach, Rethink, Theraplatform, NPAworks, Lumary, AccuPoint, and others). This brief is not about that layer. It is about the cross-functional work that sits around it: launching new initiatives across clinics, opening new clinics, integrating acquisitions, rolling out IT and compliance changes. That work is increasingly being run by a team whose tooling and process were built for a much smaller portfolio[2].
The expensive failure mode at every tier is the same. Initiatives get done, but they do not land consistently across regions, on time, in compliance, with auditable trails.
Four tiers of operating maturity, by clinic count.
Each tier is defined less by headcount or budget than by the operating mode the ops team is forced into, and the inflection point that breaks it.
Hands-On Operations
Operations still runs out of a few people's heads.
A small ops team, often a COO, a director of clinical operations, a credentialing lead, and an RCM lead, supports a footprint that has outgrown spreadsheets but has not yet earned a dedicated operations function per region. The practice management and EMR systems run the day-to-day. Everything around them, openings, integrations, payer programs, compliance, IT changes, runs in inboxes.
When the COO can no longer name every open de novo, every credentialing renewal cycle, and every cross-functional initiative from memory.
The Coordination Cliff
The footprint outgrew personal coordination before tooling caught up.
Operations has scaled to regional directors, a dedicated RCM team, a credentialing lead, an IT manager, and a clinical ops manager. The practice management system runs care delivery cleanly. The work around it, initiatives, integrations, programs, is a patchwork of spreadsheets and shared inboxes. The COO answers the same question every Monday: what is actually in flight right now?
When the COO can no longer produce an accurate, current view of in-flight initiatives, openings, integrations, payer programs, IT and compliance rollouts, without asking three people.
Operational Drag
The team handles a lot of work. It just takes too long and costs too much.
Operations has 25 to 60 people across corporate, regional, and shared services (RCM, credentialing, IT, clinical ops, training, real estate). The practice management stack runs care delivery. The corporate ops layer that runs change, initiatives, integrations, programs, is the constraint. Strategic work is starved by the volume of in-flight requests.
When more than 30% of the ops team's time is spent on coordination, status updates, and rework instead of executing.
Enterprise at Scale
Ops is a P&L line. Governance and proof become the job.
Operations runs as a portfolio: a head of ops excellence, regional COOs, and a center-of-excellence model for RCM, credentialing, IT, clinical ops, and PMO. The COO's job is governance, capital allocation, and proving operational ROI to the board and PE sponsor. Across the program-and-initiative layer that sits around the practice management stack.
When the question shifts from whether ops work is getting done to whether the right work is funded, and whether anyone can prove it.
Find your stage. See the challenges, the impact, and what fixes them.
Drag the slider to the size of your footprint. The rest of this section reflects the cross-functional ops challenges most likely to be hurting your team right now, with the corporate and clinic-level impact, and how a platform like Workzone resolves each one.
The Coordination Cliff
The footprint outgrew personal coordination before tooling caught up.
This is the most painful tier. The portfolio is too large for personal coordination but too small to justify a full operations COE. Regional ops directors run their own playbooks. Corporate finds out about a problem when an accreditation finding lands, when a state license lapses, or when a planned payer rollout is silently three months late in two regions.
Inconsistent rollout of corporate initiatives across regions
A new payer contract, policy update, or compliance change is supposed to roll out system-wide. In practice, some regions absorb it within a week, others within a month, others not at all.
Coordinated rollouts under-deliver. Compliance and revenue risk concentrate in the regions that did not adopt.
Two clinics 30 minutes apart operate under different versions of the same policy or contract. Inconsistency becomes the local norm.
Run system-wide rollouts as a single project with regional rollout tasks, clear go-live dates, and a live status board.
Workzone projects roll up regional rollout tasks under one parent program with dependencies and a single source of truth for go-live status.
Score your operating maturity in 2 minutes.
Set your clinic count, answer 12 yes-or-no questions distilled from the tier challenges above, and get a maturity score, your tier label, and the three highest-impact gaps to close first.
120 clinics · Tier 2 · The Coordination Cliff
Mark each statement yes if it is true today, no if it is not.
- 01Critical at T1
Initiative requests come in through one front door with a structured brief, not Slack DMs and shared inboxes.
- 02Critical at T2
Anyone on the leadership team can see what initiatives and programs are in flight at the corporate and clinic level.
- 03Critical at T1
New clinic openings run from a templated ops playbook with pre-wired owners, dependencies, and dates.
- 04Critical at T2
System-wide policy or payer changes reliably take effect on the same day across every site.
- 05Critical at T1
Credentialing renewals, payer enrollments, and license filings are tracked as a program with reminders, owners, and a per-cycle audit trail.
- 06Critical at T2
Policy, compliance, and accreditation reviews flow through a structured workflow with named approvers, attestations, and a per-version audit trail.
- 07Critical at T3
External reviewers (outside counsel, accreditation surveyors, partner clinical leads) can review on the document itself, not over email.
- 08Critical at T3
The COO or Head of Operations can show committed work versus team and vendor capacity in real time.
- 09Critical at T3
Executive and board reporting on initiative throughput and on-time delivery is a query, not a manual monthly reconciliation.
- 10Critical at T2
Acquisition integrations spin up from a templated program on day one of close, not improvised per deal.
- 11Critical at T2
All vendor and contractor work is visible in the same workspace as in-house work, with scope and status.
- 12Critical at T3
A new ops hire can land and contribute in their first two weeks because processes, owners, and templates are documented in the system.
- 13Critical at T3
When a project misses deadlines or budget, we can clearly identify the root cause of the variance.
- 14Critical at T3
We can accurately forecast project timelines, budgets, and resource needs before issues occur.
The operating layer that resolves these challenges.
Most of the failures above are not clinical failures, and they are not practice management failures. Your EHR and scheduling system are doing their job. The failures are coordination failures at the program-and-initiative layer: work done in the wrong order, by the wrong people, with the wrong context, and proven by the wrong artifacts.
Project management software does not replace the practice management stack and should not try to. It sits next to it and runs the change layer, openings, integrations, programs, rollouts, audits, that the practice management system was never built for. The seven capabilities below are what platforms like Workzone deliver, mapped directly back to the tier-by-tier challenges above.
A single front door for initiative requests
Standardized intake forms by request type with required fields for site, region, business case, urgency, and due date. Nothing enters the queue half formed.
Templated playbooks for repeatable work
Reusable project templates for new clinic openings, acquisition integration, payer rollouts, IT migrations, and accreditation cycles, so every program starts from a baseline plan that has worked before.
Cross-team visibility dashboards
Live views by region, function, and program, so the COO, regional VPs, and the PE sponsor see the same status without manual reconciliation.
Credentialing, licensure & enrollment programs
Recurring workflows with reminders, document storage, and a per-cycle audit history that survives a payer or regulator audit. Feeds the credentialing system; does not replace it.
Structured policy & compliance workflows
Sequenced reviews with named roles, deadlines, attestations, comment threads attached to the document, and a permanent audit trail of who approved which version when.
Capacity and resource planning
A forward view of committed work versus team and vendor capacity, so the COO can negotiate tradeoffs instead of absorbing every new request.
Roll-up reporting across portfolio
Standardized initiative status, throughput, and on-time metrics that aggregate from project to region to portfolio. Executive reporting becomes a query, not a weekend.
Why we publish on multi-site healthcare.
Workzone is project management software built for operations, marketing, and IT teams, with more than 23 years of real-world deployment experience and a 7 year average customer lifetime. We focus on multi-site, multi-stakeholder organizations where work has to land consistently across many locations and many reviewers.
Multi-site healthcare (health systems, behavioral health platforms, ABA, dental support organizations, and physician groups) is one of the categories where that focus matters most. These organizations have real compliance review, regional autonomy, an aggressive expansion cadence, and census pressure all running through the same operations team. Alongside, not inside, their practice management systems.
We publish briefs like this one because the operating-layer conversation is one of the highest-leverage ones a multi-site COO can have, and it is rarely had with the specificity it deserves.
See what the multi-site ops change layer looks like in Workzone.
Book a 30-minute walkthrough with a Workzone multi-site specialist. We'll map the framework above to your current tier and show you the specific workflows other multi-site healthcare ops teams use to run the change layer around their practice management stack.
"We were getting things done, but our team was getting crushed. There was no work-life balance. Everything was a ‘just do it’ project—we called them ‘Nike projects.’ Workzone helped us get out of survival mode. Now we’re working smarter, prioritizing better, and aligning with what really matters to the organization."
Sources.
- [1]Brown University / JAMA Pediatrics: Private equity firms acquired 574 autism service delivery sites across 42 states between 2015 and 2024 (147 deals). https://www.brown.edu/news/2026-01-07/private-equity-autism-centers
- [2]L.E.K. Consulting: Investing in Autism Therapy. Key Trends Shaping the U.S. ABA Therapy Sector (June 2025). https://www.lek.com/insights/hea/us/so/investing-autism-therapy-key-trends-shaping-us-aba-therapy-sector
- [3]CDC: Autism prevalence reached 1 in 31 children (ADDM Network, 2023 surveillance year). https://www.cdc.gov/ncbddd/autism/data.html
- [4]VG Software: State of ABA Therapy 2026. Industry Report for Practice Owners. https://vgsoft.co/blog/state-of-aba-therapy