As the U.S. health care environment continues to evolve in response to calls for lower cost, higher quality and an improved patient experience, health care organizations are undergoing fundamental change. This in turn requires the system Chief Nurse Executive (CNE) to adjust and embrace new competencies. These include improving population health, increasing quality, expanding provider coverage and managing increasingly complex health information technology systems. System nursing leaders must take on these issues while at the same time ensuring safety across the continuum of care and keeping financial viability in mind. The system CNE must also remain prepared to respond to evolving changes in ownership or partnership of their health care organization.