You pretty much described that last job. They outsourced a lot in the past decade, but now the issue is that to do what they want to do, they can't because of outdated tools and infrastructure. They don't have the expertise in-house. They keep talking about "leading" and "pioneering" work, but by definition, if you're buying off the shelf products that solves a problem, it's not pioneering.

The problems they want to solve require an engineering culture. There are no ways around that.

Like many hospitals, they've been hit hard by COVID-19. They recently announced golden handshakes for people close to retiring. It's painful for people now, but hopefully someone will see it as an opportunity to change the culture.