An era of increasing budgetary constraints, misaligned payers and providers, and a competitive system where United States health outcomes are outpaced by less well-funded nations is motivating policy-makers to seek more effective means for promoting cost-effective delivery and accountability. This article illustrates an effective working model of regional collaboration focused on improving health outcomes, containing costs, and making efficient use of resources in cardiovascular surgical care. The Virginia Cardiac Surgery Quality Initiative is a decade-old collaboration of cardiac surgeons and hospital providers in Virginia working to improve outcomes and contain costs by analyzing comparative data, identifying top performers, and replicating best clinical practices on a statewide basis. The group's goals and objectives, along with 2 generations of performance improvement initiatives, are examined. These involve attempts to improve postoperative outcomes and use of tools for decision support and modeling. This work has led the group to espouse a more integrated approach to performance improvement and to formulate principles of a quality-focused payment system. This is one in which collaboration promotes regional accountability to deliver quality care on a cost-effective basis. The Virginia Cardiac Surgery Quality Initiative has attempted to test a global pricing model and has implemented a pay-for-performance program where physicians and hospitals are aligned with common objectives. Although this collaborative approach is a work in progress, authors point out preconditions applicable to other regions and medical specialties. A road map of short-term next steps is needed to create an adaptive payment system tied to the national agenda for reforming the delivery system.