Despite hospital boards' overall responsibility for quality of care, studies have shown that they do not always consider patient safety to be their chief priority. The Joint Commission raised concern about this issue in a 2009 sentinel event alert calling for greater leadership engagement to ensure a culture of safety. This systematic review attempted to characterize the patient safety activities and time commitment of hospital managers and boards. Review of the predominantly United States–based literature found that both boards and managers often spend less than 25% of their time on quality-related activities, and it revealed that establishing a formal board quality committee and linking compensation to quality measures may have positive effects on safety. However, the conclusions are severely limited by a lack of empirical studies and variations in definitions of management structures and outcomes. An AHRQ WebM&M interview discusses the role boards can play in improving safety, and a commentary illustrates how senior management can effectively manage disruptive behavior by clinicians.