Governing boards of hospitals and health systems are examining their responsibility for the quality of care delivered in their organizations with new vigor in the context of recent attention to medical errors and patient safety and the proliferation of patient safety initiatives. Organizational performance improvement begins with effective governance. This article describes the legal and regulatory expectations for boards and implementation strategies for board leadership in quality and safety improvement. The article also explains the role that trustees can play in resolving uncertainties about the confidentiality provided by Virginia’s law protecting peer review and quality improvement information. Confidentiality permits the candid investigation, analysis and discussion of adverse events that are necessary for quality and safety improvement.