COVID-19 exposed competing forces within the missions of many standalone hospital systems. These forces include a rugged American individualism on one hand and the desire to efficiently meet the healthcare demands of their communities on the other. Both are valid considerations, but they are often in conflict. By definition, individual entities stand outside the safety of the collective, forging their own distinct paths to their own unique destinations. Efficiency, however, is most often associated with uniformity, consistency, scale, and centralized decision making. This article explores that tension and considerations for hospital boards as they work to best position their organizations in an evolving industry.