The volume of surgeries and the number of hospitals where they are performed have both decreased dramatically in the years since NYS first began reporting risk-adjusted outcomes for pediatric cardiac surgery. In 1997, 16 hospitals performed 1749 pediatric cardiac surgeries. By 2009, there were only 10 hospitals performing 1304 surgeries. The average number of surgeries per hospital in 1997 was 109 compared to 139 in 2010. Many factors, including increased use of catheter-based therapies, may have contributed to the overall decline in the number of surgeries. The overall mortality rate for pediatric cardiac surgery dropped from 4.08 % in 2002 to 2005 period to a mortality rate of 3.35 % in 2006 to 2009 period with no major changes in overall patient risk, although part of this decrease may also be due to improvements in the field in general. A multivariable analysis demonstrated that a dedicated pediatric cardiac ICU proved to be a significant independent predictor of mortality. The methods for assessing patients' risk of in-hospital mortality have changed with each successive report, and this study describes the current method and the risk factors used in the method. The Department's other initiatives for improving quality, including consolidation of services, linking processes and structures of care to outcomes, and other regulatory actions, are also described.