The evaluation, performance, and subsequent care of tracheostomy patients is a critical component of airway management for the otolaryngologist. Despite tracheostomies prevalence, the knowledge regarding the best practices for caring for persons with a tracheostomy is not widely known. We will discuss the current state of tracheostomy care and the most effective methods of reducing practice variability, in-hospital complications, and unplanned readmissions. We will describe building tracheostomy management programs using the principles of high-reliability organizations. Furthermore, we will discuss the management challenges and solutions to various difficult tracheostomy-related problems. We will discuss both pediatric and adult programs, as well as, our experience with COVID tracheostomies in both children and adults.