Background: A sustainable, standardized approach for quality assessment and improvement is increasingly expected in oncology. This requires oncology leaders to identify processes and infrastructure to facilitate sustainable initiatives for practice refinement. To date, few summative reports of lessons learned, key success factors, and barriers to regular quality improvement have been reported. Methods: After IRB protocol approval, a focus group of 11 diverse physician oncology leaders was conducted, using a guide developed through multiple discussions by investigators. The physicians represented diverse organizations with community-based, private practice and academic settings. Data analysis of interview transcripts was performed iteratively, with a grounded theory approach with a method called “constant comparisons”, with related open and axial coding techniques. Transcripts were coded independently by two or three coders, and the resulting code lists integrated prior to final analysis. Differences in coding were resolved by consensus. Results: Overall, physician quality leaders discussed needs and barriers in 5 major domains: coordination of care, communication, finances, value, and quality improvement. Two major themes emerged: rapid change cycles in a dynamic landscape of practice--changing business models and care delivery, new expensive drugs, oral chemotherapy--and their respective unintended consequences on quality of care, e.g. financial toxicity for patients, misalignment of financial incentives and a quality agenda. Participants discussed responding to these changes and key factors in harnessing the practice model to deliver quality care. Conclusions: Cancer care delivery is rapidly evolving and undergoing intrinsic cycles of quality improvement. This project helps to inform systemic quality improvement efforts targeted towards oncology practices by identifying areas of concern and highlighting key factors to be addressed to achieve value, alignment and quality of care. Institutional culture and infrastructure including resources and incentives for quality improvement/measurement were identified as critical success factors.