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Several characteristics of academic health centers have the potential to create high levels of internal conflict and misalignment that can pose significant leadership challenges. In September 2000, the positions of Ohio State University (OSU) senior vice president for health sciences, dean of the medical school, and the newly created position of chief executive officer of the OSU Medical Center (OSUMC) were combined under a single leader to oversee the OSUMC. This mandate from the president and trustees was modeled after top institutions with similar structures. The leader who assumed the role was tasked with improving OSUMC's academic, clinical, and financial performance. To achieve this goal, the senior vice president and his team employed the service value chain model of improving performance, based on the premise that leadership behavior/culture drives employee engagement/satisfaction, leading to customer satisfaction and improved organizational performance. Implementing this approach was a seven-step process: (1) selecting the right leadership team, (2) assessing the challenges and opportunities, (3) setting expectations for performance and leadership behavior, (4) aligning structures and functions, (5) engaging constituents, (6) developing leadership skills, and (7) defining strategies and tracking goals. The OSUMC setting during this period provides an observational case study to examine how these stepwise changes, instituted by strong leadership and teamwork, were able to make and implement sound decisions that drove substantial and measurable improvements in the engagement and satisfaction of faculty and staff; the satisfaction of students and patients; and academic, clinical, and financial performance.