There is one part of every hospital that will largely determine whether it thrives in the decade ahead: the procedural environment. Peer-reviewed analyses estimate that operating rooms alone account for 60 to 70% of revenue and 35 to 40% of costs. Over time, and through years of research studying procedural environments, I realized the bigger opportunity was improving the systems in which they work. Much of what drives risk in surgery comes from process, workflow and system design, not technical skill alone. When those systems work well, teams perform at their best.