What does it take to make changes in practice and sustain those changes over time? This paper describes 3 successful attempts to improve the quality of care at US hospitals participating in the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology [ACC]/American Heart Association [AHA] Guidelines), the Guidelines Applied in Practice (GAP), and the Get With The Guidelines (GWTG) programs. Techniques that work at the local level and practical tips that can be adopted to develop quality improvement (QI) initiatives are highlighted.