In this chapter, the author discusses leadership and governance issues in implementing curricular reform at the eight schools that participated in The Robert Wood Johnson Foundation's "Preparing Physicians for the Future: Program in Medical Education." Leadership is defined as the roles played by key individuals within a school in facilitating significant curricular change; institutional governance is the administrative structure through which the curricular changes were administered. The characteristics of successful leaders as well as problems caused by poorly chosen leaders are described. The author also discusses how leaders handled resistance to change and the role of students in overcoming this resistance at some institutions. The second half of the chapter focuses on governance structures. The author briefly discusses the role of curriculum committees, how student and faculty committees at some schools worked to implement change, and the implementation at each of the eight schools of a centralized education budget. He concludes with a list of characteristics of successful leadership and successful governance in the process of curriculum reform.