Analyzing survey and administrative data, this study links a transformational leadership style, in which health care leaders articulate a clear and shared vision for an organization, to a positive safety culture. The authors also found that a culture of safety was associated with robust continuous quality improvement. However, having improvement activities in place was correlated with higher rates of hospital-acquired conditions, according to data collected for the Hospital Compare Web site. This finding suggests that improvement initiatives themselves may not be sufficient to prevent adverse safety outcomes; for example, hospital-acquired conditions may in fact lead to interventions. The authors advocate for establishing both continuous quality improvement and a culture of safety to augment outcomes.