Health care systems are changing at an unprecedented rate, but few are making the changes in a system affecting nearly 200,000 staff in over 1,100 different sites of service delivery originating from 171 medical centers nationwide, as is the Veterans Health Administration. The issues of change, quality of care, morale and opportunities involved in being a nurse today in a system undergoing this magnitude of change is presented within the framework of the quality of care initiatives that have been launched by VA. The new organization design of VA, emphasizing local decision-making, a description of the multiple quality programs recently introduced and integrative strategies that have been used by the Nursing Strategic Healthcare Group, the VA corporate level policy and nursing programs information center for the country, to support the change process are discussed.