How we work
Diagnose. Design. Deliver. Transfer.
One method at every altitude, from a multi-site group to a health system. Four phases, a named artifact from each, and fees gated to milestones and measured results.
The Operating Review.
The artifacts are yours whether or not you ever engage us again — that is deliberate.
Diagnose
Where the organization loses time, capacity, and money — quantified against your own numbers, from the floor to the leadership table. Strictly outside the patient record.
You keep: the Leak Ledger
Design
The moves worth making, with cost and return attached — including “do nothing” and “buy the app” where that is the honest answer. Sequenced so the early wins fund the harder changes.
You keep: the Decision Memo
Deliver
The operating model, workflows, and automation — built with your teams, installed alongside your systems, measured as it lands. Change management is part of delivery, not an add-on.
You keep: the Install & Measure plan
Transfer
The capability stays when we leave: owners named, playbooks written, managers trained, and a benefits check after the dust settles. The opposite of a dependency.
You keep: the Playbook
Four ways to engage.
A ladder, not a menu — most organizations climb it one rung at a time, and each rung stands on its own.
The working session
Free · 30 minutesThe front door for every organization.
Your leadership question on the table — access, capacity, staffing, a stalled AI decision, a program that has to land. You leave with an honest read on the moves worth making, including when the answer is an off-the-shelf app, free supports, or nothing at all. No pitch, no deck.
The Operating Review
Fixed fee · 3–6 weeksThe paid diagnostic — and the artifact-rich front half of every engagement.
We map how the organization actually runs, quantify where it leaks, and return the Leak Ledger and Decision Memo. Fixed fee agreed in writing before we start. Many clients stop here and execute themselves — the artifacts are built for that.
The transformation engagement
Milestone-billed · 8–16 weeksThe redesign, delivered and transferred.
Operating model, workflows, AI and automation adoption — built with your teams, installed, measured, and handed over with the Playbook. Fees gated to milestones you can verify; a benefits-realization report at 90 days says what actually changed, in your numbers.
The fractional operations partner
Retainer · by agreementSenior operational judgment on standing call.
For groups and networks that need an operations lead's thinking without the salary line: standing cadence, first call on new decisions, and continuity across everything already installed.
System and network advisory is scoped per program — the practice page explains how. Or email contact@tosc.ca — every message gets read.
The guarantee
We measure ourselves in your numbers. In writing.
Consulting has earned its reputation for unaccountable invoices. This firm is built against it, in two written forms:
Clinic-scoped implementations
Outcome-linked fees: the metric we agree on at signing moves at the 60-day re-measure, or the implementation fee isn’t billed. No interpretation, no negotiation.
Programs & advisory
Milestone-gated fees — you pay as verifiable stages land — and a benefits-realization report at 90 days that states what changed in your numbers, whether it flatters us or not.
Foundation engagements.
Three organizationsThe first three organizations engage at a founding fee, set in scoping — in exchange for one thing: a written, anonymized before-and-after result we can publish. You get the full engagement and the guarantee; we get the evidence. When the three are taken, standard pricing applies. Three is not a marketing device — it is the honest limit of a deliberately small firm.
Ask about a foundation placeHow we price.
Fixed fees and milestones, set in writing before work starts, sized to the organization. As a working anchor: Operating Reviews typically run $5,000–$12,000 for a practice group and $15,000–$25,000 for networks and systems; transformation engagements are scoped from the Review’s findings. No hourly meters, no retainers that quietly renew, no discovery phases that exist to sell the next phase. If a scope genuinely grows, we re-contract in daylight. The working session and the readiness diagnostic are free — and stay free.
Fair questions.
What does an engagement cost?
The working session is free. The Operating Review is a fixed fee, set in writing before work starts and sized to the organization. Transformation engagements are milestone-billed — you pay as verifiable stages land, never on faith. Fractional arrangements are a flat monthly retainer. No hourly meters, no change orders for things we should have foreseen; if scope genuinely grows, we re-contract in daylight.
How does the guarantee work now?
Two forms, both in writing. Clinic-scoped implementations carry outcome-linked fees: the metric we agree on moves, or the implementation fee isn't billed. Programs and advisory carry milestone gates plus a benefits-realization report at 90 days — we measure ourselves in your numbers and show you the result, whether it flatters us or not.
Do you access our EMR or patient records?
No. Everything we design and build runs alongside your clinical systems — never inside the patient record. Any AI involved in our own tooling runs on infrastructure we control, in Canada, aligned with PIPA-BC and PIPEDA.
Why not just buy the app? There's software for most of this.
Often you should — and we will name the app on the first call and step aside. Software configures tasks. It cannot diagnose which of your twelve problems is the constraint, redesign an operating model, resolve cross-site politics, carry a privacy review, or own adoption across your people. Every organization we meet already owns tools it never adopted. That gap is the work.
Who actually does the work?
Himanshu Khetarpal, directly — the person who scopes the engagement delivers it and stays accountable end to end. Specialist support is brought in when a program genuinely calls for it, never as a substitute, and never as a junior pyramid learning on your time.
Do you work outside British Columbia?
BC is home and where the privacy rules and program landscape are known cold. Engagements elsewhere in Canada are taken case by case — the operational patterns travel well; the regulatory specifics get re-verified per province.
Start with the free thirty minutes.
Worst case, you leave with an honest read on your operations and the name of the app that solves your problem without us.