Quality improvement is the key to providing universal access to affordable high quality health care to all Americans. By eliminating the major quality problems of overuse and misuse of health services, quality of care can be improved and costs reduced at the same time. Thus, resources can be made available to provide necessary and effective care to those currently left out of the system. Three strategies exist for improving quality: regulation, professionalism, and competition. Each has strengths and weaknesses. Achieving quality improvement for populations will require a blend of all three strategies. The New York State Department of Health uses such a blended strategy to improve quality of care for patients undergoing cardiac surgery. This program includes regulation that strictly limits the number of hospitals permitted to offer cardiac surgical services, a professionally driven effort to improve outcomes following coronary artery bypass surgery, and the competitive peer pressure generated by publishing hospital and surgeon-specific mortality data. During the first four years when all three components of the program were in effect (1989-1992), risk-adjusted operative mortality following CABG surgery fell by 41%.