In 1991, Plsek sought to improve the quality of health care by challenging the readers of Crossing the Quality Chasm to find the few simple rules that might guide the local development of the 21st century health system. We have analyzed our health system's activities in the context of systems science as it seeks to create value (improve population health and patient experience, and reduce costs) for its stakeholders. We have concluded that 5 rules are simultaneously necessary and sufficient for success: 1) The stakeholders agree on a set of mutual, measurable goals for the health system; 2) the extent to which the goals are being achieved is reported to the public; 3) resources are available to achieve the goals; 4) stakeholder incentives, imperatives, and sanctions are aligned with the agreed-on health system goals; and 5) leaders among all stakeholders endorse and promote the agreed-on health system goals.