Academic medical centers have a duty to serve as hospitals of last resort for advanced cardiac surgical care and therefore manage patients at elevated risk of postoperative morbidity and mortality. They must also meet state and professional quality targets devised to protect the public. The tension between these imperatives can be managed by a multidimensional quality improvement program that aims to manage risk, optimize outcomes, and exclude futile operations. We here share our approach to this process, its impact on our institution, and discuss pertinent issues relevant to institutions in a similar situation.