Academic Medical Centres (AMCs) have to constantly balance the multiple objectives of research, education and clinical care. Within clinical care, they have to balance growth, the patient experience, staff engagement, clinical outcomes, and efficiency. While this nuanced balancing act is difficult in any organisation, they are more so in AMCs where the organisational boundaries, priorities and goals are not well-defined. In this session, we will present a case study of how the Stanford Cancer Centre addressed these issues. Over the last eight years, our Cancer Centre has increased new-patient visits by 74% and total visits by 60%. Patient satisfaction has improved from the 6th percentile to the 93rd percentile, and staff engagement from the 27th to the 80th percentile, both measured on a national basis. Efficiency—as measured by cost per unit-of-service—has improved about 4% year-over-year. This case study will focus on the role of leadership and a change-management framework that led to these results. We will also discuss the mistakes that we made and lessons learned that could be applied to other AMCs. Finally, we will offer the scaffolding for a change model that leverages arbitrage theory and sense-making in loosely-coupled systems.