Leadership commitment to improving safety is a key component of safety culture, the importance of which was highlighted by The Joint Commission through a Sentinel Event Alert in 2009. However, a recent survey of hospital board chairpersons found that most did not consider patient safety or quality of care to be their top priority. This article discusses the historical role of hospital boards and medical staff leadership, and discusses strategies for boards and medical staff to respond to the challenge of ensuring patient safety. An accompanying editorial calls for physicians to take an active role in developing leadership and reporting structures to ensure an organizational focus on patient safety. The role of hospital boards in safety and quality improvement was discussed in an AHRQ WebM&M perspective.