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Objectives: Fifty years ago, Donabedian described the conceptual framework for quality in healthcare as the triad of process, structure and outcome. These principals were applied to a failed urban cardiac surgery program (volume, efficiency, and quality) in an underserved county of 900,000 people in which cardiovascular death rates are up to double the neighboring county and public health studies demonstrate high rates of cardio metabolic syndrome as well as poor access to health care. Using Cardiac Surgery as a highly measured clinical service model our hypothesis was that strict attention to all details related to Donabedian’s triad would achieve acceptable quality of care in Cardiac Surgery.Methods: The 205 patients undergoing coronary artery bypass (CAB) formed the study group. We performed a preliminary 6 month planning process evaluating and improving equipment, human resources, facilities, and patient care protocols. Emphasis was placed staff education. This process was facilitated and modeled through training and oversight by a medical school/academic health center. All structure and processes and of care including preoperative, intraoperative, and postoperative protocols were recreated and rehearsed prior to program re-start. Data for all cardiac operations were recorded using the Society of Thoracic Surgeons National database (STS).Results: 205 coronary consecutive artery bypasses (CAB) were performed. Medical comorbid conditions were higher than the STS national mean. However, the risk adjusted outcome data for the first 205 CAB population yielded a mortality of 0.5% (expected 2.5%; O/E= 0.20) as well as a complication rate (Table 1) lower than expected. The first STS rating was 3-star for CAB, 2017 (top 10% of >1000 cardiac programs, p<0.05) indicating strict adherence to a quality-first standard of care.Conclusions: Strict attention to the process and structure fundamentals and details of Cardiac Surgical care in an underserved at risk population can result in acceptable outcomes and quality measures at low program volume.