Ten years ago, the culture of healthcare could be described as “permanent whitewater.” External regulations, advancements in technology, financial constraints, and consumer expectations contributed to the turbulence. Today, core issues in healthcare, which include quality improvement, cost containment, and patient satisfaction, remain fairly unchanged from ten years ago. However, the intensity and pace has escalated. Reports such as the 1999 Institute of Medicine “To Err is Human” and “Healthy People 2010” set in motion critical initiatives to provide safer and more equitable healthcare. These demands for safe and affordable care, along with regulations and legislation are shaping healthcare environment. In the midst of this crucible, positive outcomes are being realized. Innovation, standards of excellence, patient family involvement, pursuit of recognition and expansion of evidence based practice are visible in many hospitals across the nation. This presentation will take a look at the current issues and trends in healthcare and use these to discuss emerging directions in healthcare. The response to key questions will shape the future. Are we measuring the right outcomes? Do safety measures really contribute to safer care? Are all of these measures really leading to improved outcomes? Are we creating a wider gap between hospitals of excellence and others? We are at a point in healthcare where our response to the demands for positive outcomes and the competition of quality based recognition can transform the provision of care, moving us to be proactive rather than reactive to the swirl of whitewater.