Over the past decade, patients, payers, government, and others have increasingly scrutinized the care physicians deliver. Pay-for-performance programs have enabled payers to hold providers accountable for performance on quality measures. Public reporting has made quality and safety data more transparent. More and more providers are now being held accountable for the cost of care in addition to quality. It is critical to have physicians intimately involved in these efforts, yet hospitals and health systems struggle to engage them in improving care. Furthermore, much of the focus on health care redesign has been on primary care physicians, despite the fact that specialty care is responsible for the majority of health care spending. To engage specialists in care improvement, The Brigham and Women’s Physicians Organization (BWPO) has launched several programs, among them the creation of departmental “Directors of Performance Improvement” (DPI) which we’ll describe here.