An overarching goal for surgery is to deliver high-quality care, defined as being safe, effective, efficient, patient-centered, timely, and equitable,¹ but achieving this multicomponent goal has proved challenging. The last 2 decades have seen substantial endeavors to address quality deficits in surgery through targeted quality improvement (QI) efforts. The interventions deployed include checklists, briefings and debriefings, clinical pathways, and many others—and the Accreditation Council of Graduate Medical Education is currently requiring more formal improvement instruction and experience for postgraduate trainees. Despite the volume of activity, evidence persists of preventable mortality and complications, inefficiencies, disparities, and unwarranted variability, suggesting that suboptimal care is a much less tractable problem than perhaps was anticipated at the dawn of the quality and safety movement.² It is now clear that QI itself requires improvement. We offer 3 observations to help in addressing this urgent need.