This presentation gives an overview of how one EMS agency has adapted to the challenge of evolving protocols, technology, and provider competencies when it comes to patients requiring emergency cardiovascular care or CPR. In 2012, Pennsylvania began a roll out of high performance CPR throughout the state. Since then, Cumberland Goodwill has experimented with training via taped performances, manual CPR with metronomes, manual CPR with device assistance, mechanical CPR, manual intubations, rescue airways, passive oxygenation, video intubation, different heart monitor brands, and found that in the midst of our quest to do resuscitation "better", not only did our procedures need to change, but how we defined successful practice needed to change too. Through the use of checklists, CARES data submissions, an a re-tooled CQI process, Cumberland Goodwill built a process that doesn't just measure CPR success via a patient living or dying, but also guides the practice of resuscitation, driving improvement even amidst good outcomes after bad procedures. The presentation will present case studies showing some of the recent challenge areas, including Pacing, Synchronized Cardioversion, and intubation. It also will discuss methods used to improve citizen CPR engagement (and willingness to act) and about making the CQI process less of a chore for providers and more useful for administrators.