This article discusses the responsibility and accountability for quality improvement and safety in health care organizations from the top down: from the governing board, to CEOs and other executives, to all staff. Patient safety and quality measures, challenges to implementing such efforts, and the future of governing board involvement and executive accountability are discussed. The article includes six activities all boards should do to improve quality and safety, as recommended by the Institute for Healthcare Improvement. Shared with the permission of the ECRI Institute.