Aperfect storm is developing as this decade closes. Hospital investment revenue is in a free fall, selfpay revenue streams are at risk, and capital acquisition is challenging against a backdrop of a global financial collapse. However, just when it could not get any worse, a tsunami that has been quietly building offshore for years in a climate of stakeholder unrest now threatens all but the best prepared. New cresting workforce issues, transparency pressure, strained hospital-physician relations, and now Pay-for-Performance demands have been hammering our health care leaders in ever more powerful waves. They have now coalesced into an enormous force that is bearing down on our hospitals. We contend that the drama that will play out on the health care stage will star what Malcolm Gladwell would call the Boutliers[ from his book of the same name. They will be the leaders and organizations that exhibit true greatness in a new arena of quality performance.