Original ArticlesHospital Leadership and Quality Improvement: Rhetoric Versus RealityLevey, Samuel PhD, SM*; Vaughn, Thomas PhD, MHSA*†; Koepke, Mark JD, MHA‡; Moore, Duncan MHA*; Lehrman, William PhD‡; Sinha, Sunil MD, MBA‡Author Information From the *The University of Iowa College of Public Health; †Iowa City Veterans Integrated Health System, Iowa City, Iowa; and ‡Centers for Medicare & Medicaid Services, Baltimore, Maryland. Supported by Island Peer Review Organization and Centers for Medicare & Medicaid. Correspondence: Samuel Levey, PhD, SM, 200 Hawkins Dr, E228GH, Iowa City, IA 52242 (e-mail: firstname.lastname@example.org). Journal of Patient Safety: March 2007 - Volume 3 - Issue 1 - p 9-15 doi: 10.1097/PTS.0b013e3180311256 Buy Metrics Abstract The sine qua non of leadership is high performance. Many studies and commentaries have shown that the quality of care in America is not what it ought to be. This performance gap has been attributed to failures in leadership that were perpetuated over the decades by ineffective organizational structures and processes as well as apathy, neglect, and a lack of individual and collective will. Based upon interviews in 18 community hospitals with 96 hospital leaders including CEOs, CMOs, and governing board members, this qualitative study examined interest and involvement in quality improvement. Although a high level of rhetoric in support of quality improvement exists, the reality is that the performance gap continues to persist. The authors conclude that the "three-legged stool" is in need of substantial repair. New resources, rethinking, and redesign of structures and processes are vital steps. Construction and implementation of reliable and valid measures of organizational performance are also imperative. © 2007 Lippincott Williams & Wilkins, Inc.