T he single most important ingredient for transformational high-performance improvement is leadership; yet we have a leadership vacuum at the frontline. The 3 Ts of truth, trust, and teamwork offer a conceptual framework of actions that can be taken to engage trustees, senior administrative leaders, independent and employed physicians, and frontline nurses and staff who are the servant leaders providing care. The market forces of transparency in hospital performance press the 3 Ts into action.

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... ruth is the currency of our analytical mindVfacts, data, patterns, and metrics drive the critical processes of our industry. Trust is the currency of our heartVour faith or belief in mission, the value of the common good, and the personal and organizational brand of our colleagues and collaborators. Without truth and trust built into the gears of teamwork, the machinery of our care process, we are individuals, carried along by systems inertia, delivering fragmented and production-centered health care. Many have thought that there is active resistance to performance improvement activities. When we asked Dr Don Berwick, the visionary leader of the very successful Institute for Healthcare Improvement (IHI) "100,000 Lives Campaign" that engaged more than 3000 hospitals and, to date, has contributed to saving more than 122,000 lives, 1 whether there were any surprises, he stated his observation: "We misinterpret a vacuum as if it were resistance. The campaign participants who have stepped forward as leaders fill this vacuum. Something was missing and now it's supplied with this energy to do better. It wasn't resistance; it was the absence of a clear, articulated, real meaningful opportunity to do something. People seem to focus on resistance in health careVdefects, problems, and the slowness of change. We're finding energy in the workforce that even IVand I'm an optimistVdidn't know was there. Doctors, managers, therapists, pharmacists are coming out of the woodwork. All they want to do is help and get involved. The energy level is just phenomenal. Executives, tooVI've had CEOs call me spontaneously, testifying to the meaning of this, not just in the organizations but for them personally. This is tapping something that I guess was there all along" (personal communication, August 23, 2006). Purchasing, quality, and certifying organizations are forcing us to change through their demands for transparency, which is revealing great gaps in performance.