From Burnout to Breakthrough: How Fractional COOs Like Ashish Gupta Are Transforming Healthcare from the Inside Out

Healthcare is at a breaking point, not just in terms of patient care, but in how the business itself is run. Clinics are growing faster than their operations can handle, and too often, the people leading them are overwhelmed, reactive, and stuck in the weeds. 

That’s where Ashish Gupta comes in.

As Founder of ScaleUpExec.com and 2024 CEO of the Year for Fractional COO Services, Gupta has become the go-to fixer for struggling practices. With two founder-level exits, a $2B ops budget at Apple, and 20+ healthcare turnarounds under his belt, he doesn’t just clean up messes—he rebuilds systems that scale.

In this candid Q&A, Gupta shares what’s broken in healthcare operations, why most leaders don’t even know they’re stuck until it’s too late, and how fractional leadership can deliver Fortune 500-level results without the full-time price tag. 

From aligning vision with operations to unlocking revenue in 90 days, his insights are a masterclass in modernizing the business of care.

HBT: You’ve helped turn around more than 20 healthcare businesses. What patterns do you typically see in clinics that are stuck—and where do you start first?

The patterns are surprisingly consistent, whether it’s a solo practice or a 100-person specialty clinic:

• The owner or CEO is stuck wearing too many hats, often leading both clinical and operational functions. 
• Decision-making is reactive, driven by daily fires rather than strategic priorities.
• There’s no operating rhythm—no weekly scorecard, no clear accountability structure, no regular leadership meetings with a clear agenda.

When we step in, our first move isn’t to start fixing things – it’s to get clarity. We map out the current state of the business and define a clear future state. That future state isn’t just about revenue targets or operational metrics. It includes important, often-overlooked questions like:

• What kind of life does the founder want alongside the business?
• Do they want to exit clinical work or even exit the business entirely?
• Are they seeking fast growth, or more stability and sustainability?
• Do they want to stay in the integrator role or shift to a visionary one?

These personal and strategic conversations set the direction. From there, we perform a comprehensive gap analysis to identify what’s missing between the current state and the future state.

A COO is uniquely positioned to lead this because we’re trained to look across the entire business, not just one department. That means assessing:

• Top line: How diversified and scalable are the sales and marketing channels? Is customer or payer concentration putting the business at risk?
• Bottom line: Are margins healthy? Is cash flow predictable? Where are dollars being wasted or under-leveraged?
• Team, systems, and processes: Is the organization aligned around clear goals and accountability? Are there leadership gaps or communication breakdowns? Is the culture enabling or resisting growth?

This full-spectrum view allows us to prioritize the most strategic operational shifts—ones that not only improve performance, but move the business closer to the founder’s true goals.

This current-to-future-state approach keeps everyone aligned and ensures the operational fixes we implement are in service of what really matters—both for the business and the people leading it.

HBT: How does the fractional COO model benefit healthcare organizations differently than traditional full-time leadership hires?

The value lies in both cost and caliber—but even more than that, it’s about fit and focus.

Many healthcare founders are exceptional clinicians or visionaries, but they haven’t been trained in how to build and run a scalable business. We specialize in filling that gap. Our fractional COOs are seasoned operators who’ve scaled companies to 8- and 9-figures, built teams, installed systems, and driven performance across every function of a business.

Hiring a full-time COO at that level would typically cost $300K+ per year—and often, growing clinics don’t need someone in the seat full-time. What they do need is a deeply experienced operator who can come in, build the infrastructure, lead key initiatives, and develop internal talent—all while aligning to the founder’s strategic goals.

A strong fractional COO brings that expertise at a fraction of the cost, with a focus on results rather than presence. And because they’re not embedded full-time, they maintain the altitude to see what’s really broken and move fast to fix it. 

HBT: What are some specific examples of operational changes you’ve implemented that led to rapid revenue growth?

We’ve seen material improvements in both revenue and margin—often within the first 90 days—by addressing bottlenecks in operations, patient flow, or cash collection. Here are a few real-world examples:

• 41% Reduction in A/R (Accounts Receivable), unlocking $70K+ in short order: One of our COOs stepped into a multi-location clinic that was struggling with patient collections and cash flow. By integrating ClearGage with DrChrono and building follow-up workflows owned by specific team members, we reduced patient receivables by 41%. Importantly, this wasn’t just a one-time lift—this created a more sustainable financial engine that continues to pay dividends every month.
  
• Avoided a projected 30% profit reduction through compliance restructuring: A multi-clinician practice out of Minnesota faced new state worker classification laws that threatened to significantly increase payroll costs. We created an innovative legally compliant contractor model, implemented 14 new governance policies, and redesigned financial controls. This preserved contractor relationships, eliminated the need for price hikes or layoffs, and avoided the dramatic hit to profitability.
  
• In a $10M+/year business: Implemented robust KPI tracking and rebuilt leadership team routines to focus on the metrics that mattered most, creating visibility into profitability by service line and provider. This allowed the team to make faster, data-driven decisions, streamline underperforming areas, and reinvest in growth initiatives—resulting in a 66% improvement in gross margin, a 16% reduction in monthly overhead, and revenue doubling within 18 months.

HBT: You’ve led at both Fortune 500 companies and SMBs. How does your approach shift depending on the scale of the organization?

At the Fortune 500 level, leadership is often about influencing across silos, navigating layers of stakeholders, and leading through process and structure. At the SMB level – especially in healthcare – you often have to build the plane while flying it. There’s no existing infrastructure, and the founder is often still in the mix operationally.

The biggest shift is that SMBs require more hands-on leadership. You can’t just design a strategy—you have to own the execution, train the team, and show what “good” looks like. And because the owner’s personal goals are often tightly connected to the business’s trajectory—whether that means driving aggressive growth, creating stability, stepping back into a visionary role, or preparing for an exit—those life considerations shape the strategy we build and the operational priorities we set. So, when we begin an engagement, we usually dive deep into understand how the owner’s business and personal life intersects.

HBT: Culture change is tough, especially in healthcare. What’s your go-to strategy for creating buy-in from overwhelmed clinical teams?

It starts with listening—and acknowledging the overwhelm. Most clinical teams are dealing with operational chaos layered on top of a high-stakes, emotionally demanding job. For example, most medical practices are filled with people who are exceptionally skilled at their craft, but who’ve never been trained in business. So, when we implement KPI dashboards, we do it only after building trust and relationships, involving the team in the design process, and making sure the benefits to them are clear.

How we typically work:

• Don’t launch initiatives from the top-down. Co-create solutions with frontline staff. Get their fingerprints on the plan.
• Win trust with small wins. I always look for one or two broken processes we can fix quickly—something the staff will feel immediately. That builds credibility fast.
• Keep the message simple. Everyone should understand what we’re doing, why it matters, and how we’ll measure success.

HBT: What role do tools like AI, automation, or new workflow platforms play in the kind of operational turnarounds you’re leading?

They’re essential—but only if they’re in service of a clear operational strategy.

In many of our engagements, we find that practices have already purchased and deployed tools, but very few team members are trained, bought-in, or working within clear systems and processes to make those tools useful. That’s why we start with the workflows first—what’s the problem we’re solving—and then design the tech to fit into that workflow.

For example, with the DrChrono and ClearGage example above, we didn’t just “turn them on.” We built integrated follow-up systems, trained the team on exactly how to use them, and aligned the processes around them. The result: the tools became part of the daily rhythm, rather than just another unused subscription.

We also use platforms like ClickUp or Asana to create centralized operating hubs, and AI-based tools for everything from intake workflows to predictive scheduling—but always after the workflow is crystal clear.

HBT: What’s one leadership lesson you’ve learned that you wish more healthcare executives understood sooner?

Don’t wait to build the operating system.

Many healthcare leaders grow by brute force—more patients, more staff, more locations—without ever putting in the foundational systems to scale. Then they hit a wall.

If I could give one piece of advice, it’s this: Build your operating system before you think you “need” it. That means clear accountability, scorecards, meeting rhythms, documented processes. It might feel like overhead early on, but it’s what prevents burnout, turnover, and stalled growth later.

Why This Matters for Founders Now

The healthcare world doesn’t need more vision—it needs execution. Ashish Gupta’s message is clear: sustainable growth starts with systems, not sacrifice. 

And sometimes the smartest move a leader can make isn’t doing more, but letting go of the grind to lead with clarity and purpose. For any clinic looking to grow without losing its soul, the fractional COO model might be the unlock you didn’t know you needed.

For more information, visit ScaleUpExec.com.