All too often, we see the leadership above us as obstructionist, miserly, or otherwise misguided or misaligned. This is usually not the case, but there are often communication issues up and down that create that impression and sometimes lead to an adversarial relationship. Both groups benefit by aligning their goals, and the earlier they do so, the better. This chapter will speak mostly to aligning your goals with that of your hospital, with some time at the end devoted to the medical school. They have many similarities, but some important differences. Understanding their priorities will help you to align yours. We discuss the paramount importance of understanding the finances both of your group and the group above you, hospital or medical school. There are ways to maximize your productivity to a mutually beneficial end, and being overt with leadership about this is always welcome. You should gain an understanding of what a “return on investment” or ROI means to the leadership above you, as this is a central concept to their willingness to invest in you and your group. You will gain an understanding of the downstream effect of your group’s efforts, particularly financial. It emphasizes the importance of understanding the key individuals you communicate with and how to approach situations where you are having communication issues. It concludes with how to align goals with the leadership above your group.