The province of Ontario, as a result of the First Ministers' Meeting, was committed to addressing surgery wait times in Ontario. The Ministry of Health and Long-Term Care's response to this commitment was the Wait Times Strategy (WTS) initiative, which addressed access issues with the aim of positively impacting wait times in cancer surgery. Cancer Care Ontario (CCO) was tasked with managing the cancer surgery WTS. CCO engaged in accountability agreements with Ontario hospitals to provide incremental cancer surgery volumes, in return for one-time funding. Through the use of accountability agreements, CCO was able to tie service volume delivery, quality care initiatives and reporting requirements to funding. Other elements of the cancer surgery WTS implementation included the development of wait times definitions, guidelines and targets; the use of a performance management system; facilitation by existing regional cancer leads and continued development of regional cancer programs. Eight key lessons were learned: (1) baseline volume guarantees are critical to ensuring that wait times are positively impacted; (2) there is a need to create a balance between accountability and systems management; (3) clinical quality initiatives can be tied to funding initiatives; (4) allocations of services should be informed by many factors; (5) regional leadership is key to ensuring that local needs are met; (6) data are invaluable in improving performance; (7) there is regional disparity in service delivery, capacity and resources across the province; and (8) program sustainability is an underlying goal of the WTS for cancer surgery. The implication is that accountability agreements can be leveraged to create sustainable health management systems.