This study surveyed chief executive officers (CEO) and board chairpersons around the country to assess their role in quality and safety efforts. Investigators discovered surprisingly low levels of knowledge with respect to quality, a disconnect between CEO perceptions of how well board chairs understood quality issues and their reported self-perceptions, and an association between board engagement and hospital performance on quality measures. The authors provide a series of strategic recommendations to close the reported gaps in knowledge and practice. The accompanying discussion includes methods to increase the quality literacy of the board, techniques to frame an agenda for quality in regular discussions, and suggested mechanisms for planning with incentives and maintaining a patient-centered focus.