Managing in a health care environment is not for the frail of heart or weak of spirit. Health care is a system in crisis that is exacerbated because it got there by doing what once made it successful. From 1900 to 2004, focus of health care has shifted from controlling infectious diseases to episodic care and to present-day chronic and perspective care. The system has moved from issues of mortality, to morbidity, to mobility, to quality of life, to feeling good and, finally, to looking good. Managing the delivery of health care, if you choose to accept it, is not an impossible mission, but it will be a challenging job. Obviously, the focus of managers is how the system can be designed to innovate and improve care. Organizations and professions must change not only structures and processes, but national priorities for improvement with better methods of disseminating and applying knowledge. Managers of respiratory care departments must foster the use of information technology in clinical care, must create payment policies that encourage innovation and tested performance, and must enhance education programs to strengthen and retain the health care work forces.