The sine qua non of leadership is high performance. Many studies and commentaries have shown that the quality of care in America is not what it ought to be. This performance gap has been attributed to failures in leadership that were perpetuated over the decades by ineffective organizational structures and processes as well as apathy, neglect, and a lack of individual and collective will. Based upon interviews in 18 community hospitals with 96 hospital leaders including CEOs, CMOs, and governing board members, this qualitative study examined interest and involvement in quality improvement. Although a high level of rhetoric in support of quality improvement exists, the reality is that the performance gap continues to persist. The authors conclude that the "three-legged stool" is in need of substantial repair. New resources, rethinking, and redesign of structures and processes are vital steps. Construction and implementation of reliable and valid measures of organizational performance are also imperative.