Direct-report assignment is not solely about the number
Health systems continue to debate the “right” span of control—the number of direct reports assigned to a given leader—as if a universal benchmark could resolve structural inefficiency. It cannot. Instead, unfortunately, the question reveals something about how organizations approach design. When leaders exclusively focus on ratios instead of clarifying decision rights and accountability, they tend to produce structural changes that appear clean on paper without improving how the organization functions.
Many organizations begin with benchmarks. This is not inappropriate in and of itself, because benchmarks can help identify potential misalignment of resources. Ratios are valuable when used as diagnostic tools. Comparative data can highlight areas that warrant closer examination and help quantify the financial implications of structural choices.
But the benchmark is only the starting point. The mistake would be to treat those data points as prescriptive. A restructuring based solely on ratios often reduces staff and layers but leaves underlying complexity and inefficiency intact. Decisions still move slowly and accountability remains unclear. A change that was intended as a structural fix often is little more than cosmetic change and temporary cost reduction that can, paradoxically, lead to an increase in cost over time if it cuts too deeply or imprecisely.
Part of the issue lies in the language. Span of control suggests that leadership is primarily about supervising people, reinforcing a command-and-control mindset that is out of step with how healthcare organizations operate. A more useful construct is span of accountability—a term that reframes the question from how many individuals a leader oversees to what that leader is responsible for.
In clinical settings, where the concept has been studied most rigorously, span is closely tied to workforce stability and outcomes. Nursing leadership, in particular, has demonstrated that as spans widen without appropriate support, turnover increases in measurable ways. Yet even here, the evidence does not point to a single “correct” ratio. Instead, it underscores that span must be calibrated to context: the experience of the workforce, the complexity of care delivery, regulatory requirements, and the presence of supporting roles such as charge nurses or supervisors. Accountability should be designed deliberately, not reduced to a target number.
That same logic applies beyond the clinical environment. In corporate and shared services, leaders often can manage broader spans due to more standardized work, greater use of technology, external and outsourced services, and less dependence on physical proximity. But the same reality applies: applying a single benchmark across both domains is analytically convenient but operationally unsound. It ignores the reality that different parts of the enterprise require different management models.
Beware the ratio-based solution
Where organizations most often go wrong is in sequencing. Span analysis is frequently treated as an entry point, particularly when assessments identify apparent opportunity based on comparative ratios. In reality, span should be pursued in conjunction with strategic decisions about the operating model, service design, and governance. This challenge is most common in organizations that have grown through M&A, where leadership structures are often preserved to maintain continuity, resulting in overlapping roles and fragmented accountability. These layers tend to harden over time, making it difficult to achieve the scale and efficiency that justified the transaction in the first place. Viewed through this lens, span of accountability is a diagnostic, revealing where responsibility is diffused or duplicated.
There are also practical considerations around leadership capability. Flatter structures can improve speed and clarity, but only when leaders have the experience and judgment to manage broader scope. This may mean, depending on the situation, making decisions across functions and taking ownership for outcomes that extend beyond a single team. When leaders are not equipped to do that, organizations tend to rebuild layers informally, which undermines the efficiency they set out to achieve.
A critical step in the process of organizational redesign is to define roles precisely: what (not how many) each leader is accountable for, and how decisions are made and executed within the organization. When those elements are clearly established, span becomes a reflection of design. When they are not, adjusting spans tends to produce merely superficial change.
Many organizations have grown skeptical of restructuring efforts driven purely by ratio analysis if those recommendations fail to account for operational realities or organizational culture. Benchmarking can help identify where further review is warranted, but sustainable redesign requires a deeper assessment of accountability, decision-making, workflow, capabilities, and support structures.
Organizations should get out of the habit of asking “how many direct reports should this leader have?” and stopping there. The next question, “what is this leader accountable for, and what structure best supports that accountability?” shines light. Organizations that answer that question well tend to create clearer decisions, faster execution, and more sustainable operating models. The number matters; it just should not be the only question driving the conversation.
Seven questions to ask before debating span
Many organizations consider span-of-control discussions to be exclusively a numbers conversation. A more effective approach is to consider a set of questions about how decisions are made, what leaders are accountable for, and how work is supported.
- What decisions sit at this level, and which ones should not?
- What is this leader accountable for beyond managing people?
- How experienced and autonomous is the workforce being managed?
- What support roles exist beneath this position?
- If this layer disappeared tomorrow, what would break?
- Where in the organization do we experience longer timelines for decision-making and execution of change?
- Do current spans support succession planning?
If these questions are difficult to answer, the issue is likely a problem of unclear design, not span.
