Healthcare needs to move faster. The sophistication of institutional governance must radically increase. Quickly. The health of our economy may rest on the ability of health care leadership to quickly adapt to the new paradigm: both outcome and cost matter, as well as patient satisfaction and growth. The consolidation of providers is fueling the creation of service lines where the total care for a condition or disease can be optimized. Leadership of these service lines, however, has not been structured to completely maximize the potential of the concept. The physicians and administration frequently continue to share decision-making in convoluted arrangements, as the challenge of truly assigning accountability is too daunting. The impact of the shared decision-making model is that everything simply takes too long. The good news: it is possible to create effective governance, given a shift in guiding principles and alignment of goals to increase efficiency in decision-making and effectiveness in collaboration among leadership. The question is not how; it’s when.