With expansion of health care systems across the country, close relationships need to be developed between academic medical centers and their affiliated community hospitals. This creates opportunity to integrate surgical programs across different hospitals. Herein we describe a model of surgical integration at the system level of five large hospitals. We discuss utilizing advantages that both the academic and community hospital bring to the model. A close relationship between an interdisciplinary team, which includes the academic surgical chair, a regional director liaison who was embedded in the community, individual hospital leadership, and practice plan leaders was created. Three pillars as a foundation to success were physician leadership, the use of system infrastructure and development of new processes. This resulted in development of trust, leading to successful recruitments, models of employment and expansion into novel areas of patient safety. Once created, new opportunities for programming for surgical safety across the health care were identified.