Littleton Regional Health’s CMO argues that access, staff retention, and financial sustainability in rural healthcare depend less on scale and more on how care delivery is structured and led.
Rural healthcare is often framed as a volume problem: too few patients to sustain services, too few clinicians to meet demand.
But for Richard McKenzie, DO, MBA, the challenge is more structural than statistical.
As the CMO of Littleton Regional Health (LRH), McKenzie has found that success in rural care delivery hinges on how systems are designed, and how they extend access, support clinicians, and translate care into sustainable revenue. McKenzie was elevated from interim CMO at LRH in March.
That perspective comes from experience, not theory. Before entering medicine, McKenzie spent two decades as a manufacturing engineer, where efficiency depended on aligning design decisions with frontline realities. He now applies that same principle to rural healthcare: The system only works if it works for the people delivering care.
Access Is Not Just Availability, It’s Proximity and Workarounds
Most rural healthcare delivery strategies begin with expanding access. But McKenzie makes a critical distinction: access is not just about offering services—it’s about reducing friction.
Primary care is the anchor.
“As a CMO, the way I look at providing medical services in rural communities is that the first way patients want to engage in their healthcare is primary care,” McKenzie says. “So, it is important to have primary care providers accessible for patients without them having to travel hours for care.”
But the real challenge emerges beyond primary care. Specialty services must be layered in without overextending resources. Telemedicine plays a role, but it is not a complete solution.
“In addition to primary care, you must provide other services such as specialty care using a variety of tools such as telemedicine, which can provide access to specialty care and the services patients need,” McKenzie says.
Unfortunately, telehealth can fail quietly in rural markets, and not because of clinical limitations, but because of infrastructure gaps such as broadband access and transportation barriers that still require physical coordination.
At LRH, healthcare access strategies include:
- Telemedicine where feasible
- Care coordination for transportation-dependent services
- Community-based extensions such as paramedic outreach
This reflects a broader truth: Rural healthcare access is built through workarounds, not just service lines.
Staff Recruitment Is a Culture Test
Rural hospitals often focus on recruitment pipelines, compensation packages, and incentives.
McKenzie argues those are necessary but can be insufficient.
“The most effective way to recruit clinicians at a rural hospital is to generate a collegial culture and establish relationships with clinician candidates,” McKenzie says. “A collegial culture is also important for retention. When physicians work at LRH, they can experience our collegial culture, which makes it easier for them to decide to continue working in our organization.”
That culture becomes visible quickly to candidates—and decisive in whether new clinicians stay.
“A CMO can set the pace for clinicians at rural hospitals,” McKenzie says. “If I am treating people with respect and kindness as well as having collegial discussions with them, it is easy for that to rub off on people throughout the organization. People look at how leaders behave and interact with staff members and that filters down to the frontlines.”
In rural markets, clinicians are not choosing between employers—they are choosing between lifestyles. Culture becomes the deciding variable.
At LRH, staff recruitment and retention are tied to:
- Early exposure through student rotations
- Relationship-building during training
- A visible, collaborative physician environment
Retention, in particular, is driven less by compensation and more by daily experience.
To boost retention of clinicians at rural healthcare organizations, a CMO must also promote a positive work environment, according to McKenzie.
“You need to have a culture where physicians would like to work,” McKenzie says. “At a rural hospital, clinician retention is not just about having competitive compensation. Most clinicians want to feel excited about going to work when they get up in the morning.”
Documentation Is Not Only an Administrative Task But Also a Financial Strategy
One of the least visible—but most impactful—areas of CMO leadership is documentation.
For rural health systems and hospitals operating on thin margins, documentation accuracy directly affects financial viability.
“The payers are looking for that documentation to make sure that procedures are medically appropriate and that the patient received appropriate care,” McKenzie says. “We have adopted some tools that make documentation more accurate and easier to produce. For example, we recently rolled out ambient listening technology in some of our clinics, and if that effort goes well, we will scale it for the rest of our clinicians.”
In rural healthcare, under-documentation is often mistaken for underperformance when it is actually lost revenue.
This is one of the few levers CMOs can directly influence that has both clinical and financial impact.
Why Leadership Visibility Is Operational
McKenzie’s leadership philosophy is rooted in his manufacturing background: Decisions improve when leaders stay close to the work.
McKenzie says one of the most valuable lessons he learned in manufacturing that has benefited him as a CMO is the importance of engaging frontline workers.
“We had draftsmen who generated plans for what we were going to build and there were workers on the floor who put the equipment together,” McKenzie says. “These workers had great insights on how the equipment was built and how well the equipment was designed.”
This experience helped prepare McKenzie to serve as an effective CMO.
“In healthcare, I have found that the people doing the work on the frontline typically have valuable insights when we change a process or try to improve it,” McKenzie says. “They understand the ramifications of what we are about to do, so it is helpful to have their input before you implement a change.”
As a CMO, McKenzie makes an intentional effort to engage frontline staff members.
“I try to connect with staff members through rounding and visiting their offices and clinics to see how things are going,” McKenzie says. “With that kind of engagement, a CMO can find out about challenging issues. When a CMO stays connected with frontline staff members, they will be more likely to share their frustrations and help identify opportunities for improvement.”
Overall, this translates into a highly visible leadership model:
- Regular rounding
- Direct engagement with clinicians
- Real-time feedback loops
Most process failures are not design failures; they are feedback failures.
When leaders lose visibility into frontline workflows, unintended consequences increase.
The Big Lesson: Rural Healthcare Requires System Design, Not Scale
McKenzie’s experience points to a broader shift in how rural healthcare should be viewed.
The challenge is not simply:
- Too few patients
- Too few clinicians
- Too little revenue
It is how those constraints are managed through system design.
Successful rural healthcare organizations:
- Extend care beyond traditional settings
- Build culture as a staff retention strategy
- Treat documentation as a financial engine
- Keep leadership embedded in frontline operations
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