Cardiac surgical outcomes improvement in a community hospital was driven by a physician champion working with a nurse clinical coordinator. Specific system improvements implemented were (1) nurse checklists of vital signs, cardiovascular function parameters, and life support appliance operation; (2) use of the EuroSCORE system of preoperative patient risk assessment; (3) monthly morbidity and mortality conferences; and (4) daily patient progress tracking. The hospital received 1 star (bottom 12% of hospitals for quality outcomes) from the Society of Thoracic Surgeons Adult Cardiac Database in 2006 prior to program inception, 2 stars (middle 76% of hospitals for quality outcomes) in 2007 and 2008, and 3 stars (top 12% of hospitals) in 2009. The physician and nurse together combined a strategy for clinical improvement with the cultural practices at the hospital to ensure that system improvements approved at the strategic level were implemented at the point of care. Both strategy and culture must be addressed to ensure patient outcomes improvement.