The obstacle to achieving meaningful healthcare transformation may not be a function of the integrity of reform models such as Triple Aim, but rather a by-product of the nature of healthcare stewardship. Classical definitions of health stewardship – as a governmental mandate – may be more aspirational than a reflection of reality in Canada. In Canada, healthcare is not organized as an intelligible system, but it is a disjoint matrix of services, that is governed by actions of a variety of “stewards” or power brokers – professional, governmental, non-governmental and corporate interests – that are often at odds. The complex relationships between the power brokers form the organizational culture of healthcare and informs the dynamic interplay of the power brokers that jockey for control, resulting in system disintegration that is an anathema to any healthcare reform. As a macro-level reform tool, Triple Aim is unlikely to succeed because the fundamental problem with healthcare has not yet been addressed: healthcare is ungoverned. Perhaps in the context of grassroots reform projects, the nascent principles of Triple Aim could grow, be replicated and be gently disseminated, and, by a process of reverse engineering, a model of health stewardship that is best suited to sound principles of quality care can evolve.