The lead paper, "Responsibility for Canada's Healthcare Quality Agenda: Interviews with Canadian Health Leaders," is a valuable contribution to the quality and safety improvement conversations taking place across the country. My commentary suggests a dramatic convergence of social, economic, demographic and technological forces has brought healthcare to a threshold of a perfect storm. To brace ourselves against this storm, I have suggested that we need to understand the system not as a structure but as relationships. I argue that alignment is not a concept that is particularly well understood – and we tend to focus almost exclusively on the component of structure.