· 4 min read
What Does a Fractional COO Actually Do?
The title gets used loosely. The plain version, the four categories the work covers, and who doesn’t need one.
People use the title loosely, so let me answer it plainly. A fractional COO is an experienced operator who builds the infrastructure a company needs to run without its founder in every decision. The role is part-time or defined-term, not a full-time hire.
That’s the dictionary version. Here’s what it looks like in practice.
What problem does a fractional COO solve?
Most healthtech founders don’t have an operations problem because they’re bad at operations. They have one because they’re doing two jobs. One is building the product and closing business. The other is everything underneath it: hiring, process, compliance, financial reporting, and the operating cadence that keeps a team pointed at the same goal. Founders can do both for a while. Eventually one of them starts to suffer, usually the one that isn’t visible in a demo.
A fractional COO takes the second job. Not by advising on it. By owning it.
What does a fractional COO’s work cover?
Strip away the title, and the job breaks into four categories that show up in almost every engagement.
People and structure. Org design, reporting lines, accountability frameworks, and hiring and onboarding infrastructure that doesn’t depend on the founder remembering to do it.
Process and cadence. The operating rhythm: leadership meetings, quarterly planning, cross-functional syncs, the stuff that turns a group of smart people into a team that moves together.
Compliance and risk. In healthtech specifically, that means HIPAA posture, SOC 2 and PCI readiness, data governance, and the regulatory scaffolding that becomes non-negotiable the moment a health system or enterprise customer starts asking questions.
Financial infrastructure. Investor-ready reporting, board deck cadence, KPI dashboards, and the numbers a founder needs to raise a round without scrambling to build them the week diligence starts.
I don’t hand a client a deck with recommendations on it. I build the thing, test it with the team, and stay until it holds.
What it’s not
It’s not a consultant who diagnoses a problem and leaves. It’s not a part-time executive assistant. And it’s not a placeholder until you can afford a full-time hire (though for some companies it turns into exactly that). The distinction that matters: a consultant tells you what to build. A fractional COO builds it, embedded in the company, accountable for whether it works.
Why founders bring one in
I see the same pattern across healthtech and medtech companies between Seed and Series B. The product is real. The traction is real. But the operational layer, the systems that let a company scale past the founder’s personal bandwidth, hasn’t caught up. Investors notice this before founders do. Traction gets you in the room for a raise. Operations determines whether you leave with a term sheet.
The honest caveat
Not every company needs this, and not every stage is right for it. A pre-seed company with three people usually needs a scrappy generalist, not a fractional COO. The fit is clearest for founders who have started hiring, are watching execution gaps threaten customer relationships or a raise, and need infrastructure built, not just advice.
What it looks like when it works
The tell isn’t a document. It’s a week where nothing escalates to you. Someone on your team makes a call you would have made, and you hear about it in the Monday review instead of at eleven at night. Diligence arrives and the answers already exist. Your morning goes to the product, or to the customer conversation that actually closes, because that’s the work only you can do.
That’s the whole point. Not a founder who works harder. A company that stops needing them to.
Alden Levy is the founder of Engine No. 9, a fractional COO practice for healthtech and medtech founders from Seed through Series B. He trained as a bioengineer at the University of Pennsylvania and holds an MBA from Wharton.