Wide variation still exists in the level of hospital board involvement with clinical performance, quality of care, and patient safety. Many board efforts related to quality and safety were historically more form than function.9,10 It is important to appreciate why this was the case. First, board appointment was an honor, a recognition and reinforcement of community status. Most board members were upstanding, often well-to-do members of their local community, chosen for these attributes more than any knowledge of health care. Second, health care is a rapidly changing, technology- and knowledge-intensive industry; thus, boards need to hire and rely on managers with high levels of content expertise. In the past, boards often relied on the chief executive officer (CEO) to manage clinical issues while the board focused its attention on traditional business issues: strategic planning, financial management, and community benefit. Finally, the unique aspects of medical staff-hospital relationships also conspired to keep boards away from direct oversight of clinical care. In most NFP hospitals, physicians were individual entrepreneurs, not employees of the hospital, and medical staffs had considerable leeway over their organization and practice. It was an unusual board that chose to step into the complex politics involving the relationships between medical staffs and hospitals. The result was that while boards had legal responsibility to oversee quality and safety, the de facto practice placed quality and safety oversight in the trusted hands of the medical staff, the CEO, and hospital administrative leaders.