1 Chapter I Introduction Indonesia, a vast nation with 17,000 islands, housed 3,168 hospitals in 2024. This expansive healthcare system spans an impressive 5,000 kilometers from west to east and about 1,500 kilometers from north to south, underscoring the scale of the healthcare sector in the country. However, many of these healthcare institutions grapple with the daunting challenge of executing their strategies effectively. The urgency of this issue is underscored by the fact that they often find themselves mired in poor performance and dwindling profitability, with a troubling number reporting negative EBITDA (Earnings before interest, tax, depreciation and amortization) an essential indicator of financial health. A survey encompassing 107 hospitals found 61 institutions, accounting for 57%, revealed negative EBITDA margins (EBITDA divided by Revenue). That means this hospital could not pay the operating costs from their operating revenue. The breadth of performance disparities is alarming: On the other hand, some hospitals boast positive margins of up to 50%; this stark contrast vividly illustrates the operational struggles faced by many healthcare providers in the region, highlighting the significant disparities in the healthcare system as shown in Figure I. EBITDA margin is not just a number but a critical benchmark reflecting an organization's operational efficiency and productivity. Hospitals posting negative margins signal a troubling reality: they cannot cover their operational costs with the revenue they generate. In these dire circumstances, some facilities depend on external subsidies, while others hover perilously close to closure or risk being taken over by new management. On a more optimistic note, hospitals that excel in operational management can achieve EBITDA margins that surpass 25%. These successful institutions are not just surviving, but thriving, using their profits to expand branches across multiple provinces and provide comprehensive healthcare services to more communities. 2 Figure I. Hospitals EBITDA Margin Disparity Yet, it is crucial to note that while some hospitals employ a multitude of Key Performance Indicators (KPIs), many of these metrics fail to tackle the intricate challenges of strategic execution. The underlying concern revolves around the significant disparities in management capabilities in hospital operations. The author is driven to investigate these issues further, aiming to uncover viable solutions to enhance hospital performance. This research addresses the urgent and critical challenge of navigating the complexity of hospital operations while achieving operational performance and profitability targets. This issue is intricately linked to the multifaceted nature of hospital operations, which encompasses business processes, management, clinical pathways, and healthcare ethics, and it demands immediate attention. To tackle this challenge, we propose implementing a transparent system, such as TD-ABC (Time Driven - Activity Based Costing), to simplify strategy execution and enhance hospital business processes. By identifying effective performance indicators and fostering a culture of optimism for positive change, we can better manage operational complexity.