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The episode opens as Meredith, Cristina, Derek, Callie, and Arizona talk about how Jackson now has more authority than they do as the leader of the board of directors – financially, they each only have a $15 million stake in the hospital while the Harper Avery Foundation has $175 million put in. This means he has the deciding vote in all matters, and can veto any decision the rest of them make. No one is happy about this.
Neither is Richard, who argues with Harper and tries to convince her that Jackson is unprepared for the job. She disagrees – she thinks he is exactly right for it.
Jackson comes in to meet with the group, and Arizona mentions their top priority should be bringing back the ER and getting Seattle Grace back to level one trauma center classification. But Jackson says the ER’s reopening is still a decision to be made, and the board wants new management to come in – specifically, they want to fire Owen. Needless to say, everyone, especially Cristina, is pissed. As everyone disperses, Jackson reminds them, “no one asked you to sue the hospital.”
As Owen is organizing the surgical board, he realizes they’re still low on nurses since most of them quit. Alex tells him that a kidney is ready for Jaylyn, a sixteen year old patient on dialysis, but the transplant coordinator has quit. Cristina stops by to warn him that the board wants to replace him, but Heather Brooks interrupts her – UNOS is on the phone with a heart and lungs ready for their patient.
Meanwhile, Stephanie and April are helping an ALS patient who interned at Mercy West with April and walk into his room to find a big party going on – loud music, beer, the works. The patient, Brad, fills them in: it’s his funeral, and he wants to be taken off of life support and donate his organs.
Owen finds Jackson, outraged that so many decisions are being made without his input. Derek tries to calm him down, but it escalates into a huge blowout, ending in Owen quitting.
Alex brings Jaylyn's parents to tell her the news that they’ve found a kidney for her. They find her making out with another teenage dialysis patient. At first she’s excited for her new kidney, but slowly she and her boyfriend realize what this means for them: no more dialysis dates.
Callie and Arizona call an emergency meeting with Meredith, Derek, and Cristina because Owen has quit. They’re mad that Cristina told him the private things that went on in their board meeting, and now that Owen’s gone, there’s no one around to handle all the transplant cases.
Meanwhile, Jackson is overwhelmed by his new responsibility. Bailey demands that he get rid of the ridiculous Pegasus protocols, and everyone else wants something from him, too.
Cristina and Brooks deliver the news to their 70 year old patient, Mr. Schultz, that they have found a heart and lungs for him. His former neighbor, Mr. Crump, whose wife left him for the heart and lung transplant patient, overhears and is pretty mad that Shultz is getting a transplant ahead of him. When Cristina gets the idea to give the old, 80% functional heart to Mr. Crump, he refuses to take it.
Meredith is taking a swipe at the OR board when Alex sends her to pick up Jaylyn’s kidney in Missoula. She and Jo book plane tickets. On the plane, Jo asks Meredith what it could mean that Alex has been mean to her lately. She says, “maybe he just hates you.” When they get to the hospital in Missoula, they find out that the kidney has been flown to Seattle as an unaccompanied minor, per Pegasus protocol that Jackson has yet to change.
Back at Seattle Grace, Jaylyn has locked herself in the bathroom after hearing the side effects of the medication she will have to take when she receives her new kidney. Once she finally lets Alex in, she tells him she’s scared and not ready. Alex confesses to her that he had feelings for a girl, but now it’s too late, so she should take the kidney. She agrees.
Richard and Harper continue to argue about Jackson’s new position at the hospital. He urges her to change her mind, because when Jackson fails at this, it will follow him for the rest of his career. Unbeknownst to him, Jackson has overheard the entire conversation.
Brad says goodbye to his family, and explains what will happen to him when is he taken off of life support. He reminds them there are only five minutes to take his organs, so they will have to say goodbye and leave right away. April comes in and reads the list of where all of his organs will go, and his mother takes comfort in this.
Cristina is finally able to convince Mr. Crump to take Mr. Shultz’s heart after telling him that if he can’t forgive him, he should outlive him – but there’s a pile up at the OR when she and Alex need to use it at the same time. Nobody seems to know what to do, but Jackson snaps into action and gives orders. Bailey steps in to back him up, and although they aren’t happy about it, everyone does as he says.
Later, while Meredith and Alex are transplanting the new kidney into Jaylyn, she tells him to drop the attitude and tells him how Jo fought hard for his kidney, so he should be nicer to her. When he leaves the hospital that night, he goes to the bar and interrupts Jo’s date with the OB resident to apologize. He offers to buy her a beer. She declines, but is noticeably flustered after he leaves.
Derek goes to see Owen to convince him to take his job back. He tells him nobody blames him for the crash, and he was only taking his anger out on him that morning – he’s actually just mad at the world and at Mark. Owen tells him he has to let it go.
Harper finds Richard to gloat about Jackson stepping up, but Richard still isn’t convinced he is the right man for the job. Harper disagrees with him, but she admits that he is the first man to show concern for Jackson like a father would since he was born.
That night, the papers are signed, and Cristina, Meredith, Derek, Arizona, Callie, and Jackson are officially the new board of directors for Seattle Grace. Jackson announces he is done letting the Harper Avery Foundation make the decisions for him, and fills them in on his plan. He wants to reinstate Owen as chief of surgery, and reopen the ER. Now that they are a hospital run by doctors, they need to make sure it means something. So he reveals his plan to rename the hospital The Grey Sloan Memorial Hospital and puts it to a vote. They move to rename the hospital unanimously.