The city of Pittsburgh and surrounding area of southwestern Pennsylvania face complex water quality problems, due in large part to aging wastewater infrastructures that cannot handle sewer overflows and stormwater runoff, especially during wet weather. Other problems such as acid mine drainage are a legacy of the region’s past coal mining, heavy industry, and manufacturing economy. Currently, water planning and management in southwestern Pennsylvania is highly fragmented; federal and state governments, 11 counties, hundreds of municipalities, and other entities all play roles, but with little coordination or cooperation. The report finds that a comprehensive, watershed-based approach is needed to effectively meet water quality standards throughout the region in the most cost-effective manner. The report outlines both technical and institutional alternatives to consider in the development and implementation of such an approach.