Leadership in the hospital sector has been characterized by a state of change since the early 1960s. Heavily influenced by the emergence of the principles of the Canadian health system, leadership at the time was shaped in many ways by the post–World War II construction boom. It was significantly impacted by the developing professional unions in the clinical professions and the resultant and conflicted labour relations of the 60s and 70s. The environment of leadership was in those days predominately a transactional style, and was frequently confrontational. But the many leaders of Canada's hospitals were also characterized by a caring cadre of often-colourful personalities who challenged, debated and strove to ensure adequate funding and a harmony among the diverse clinical, community and political interests confronting their organizations. The major restructuring of an ever-more expensive health system has set the stage for substantial innovation and reform as the leaders in the system integrate new technologies, personalized pharmaceuticals, devolving scopes of practice and entrepreneurial opportunities related to incentive funding. The development of leadership competencies such as the Leaders for Life framework across the health workforce will be essential to successfully guide our health delivery system into the future.