This article explores factors promoting leadership from the top for hospital quality improvement (CQI/FQM). From literature on governance, quality improvement, and organization theory, working hypotheses were developed about the effects of physician and management involvement in governance on CQIITQM adoption, board leadership for quality, and top management leadership for quality. Hypotheses were tested using a sample of 2,030 hospitals obtained by merging two national mailed surveys. Probit and logistic regression showed physician involvement in governance played a significant role in CQI/FQM adoption and board activity in quality improvement. Formal management involvement in governance demonstrated little effect on CQI/FQM adoption, board leadership for quality, or top management leadership for quality. Informal management involvement in governance, as reflected in opportunities to influence board composition, had negative effects on board and top management leadership for quality. Top management leadership for quality increased board leadership for quality. Implications are discussed.
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