Leaders of critical care programs have significant responsibility to develop and maintain a system of intensive care. At inception, those clinician resources necessary to provide and be available for the expected range of patient illness and injury and throughput are determined. Simultaneously, non-ICU clinical responsibilities and other expectations, such as education of trainees and participation in hospital operations, must be understood. To meet these responsibilities, physicians must be recruited, mentored, and retained. The physician leader may have similar responsibilities for nonphysician practitioners. In concert with other critical care leaders, the service adopts a model of care and assembles an ICU team of physicians, nurses, nonphysician providers, respiratory therapists, and others to provide clinical services. Besides clinician resources, leaders must assure that services such as radiology, pharmacy, the laboratory, and information services are positioned to support the complexities of ICU care. Metrics are developed to report success in meeting process and outcomes goals. Leaders evolve the system of care by reassessing and modifying practice patterns to continually improve safety, efficacy, and efficiency. Major emphasis is placed on the importance of continuity, consistency, and communication by expecting practitioners to adopt similar practices and patterns. Services anticipate and adapt to evolving expectations and resource availability. Effective services will result when skilled practitioners support one another and ascribe to a service philosophy of care.