Within healthcare institutions, leadership is an essential driver of expectations, performance, and culture. Yet boards of directors traditionally played a limited role in overseeing healthcare quality, providing final approval of credentialing decisions but deferring to the medical staff to set standards for the institution. Case law and standards provide little guidance for board performance in overseeing quality of care. Recent developments--the availability of comparative quality data, public reporting, and financial incentives for higher quality--have transformed expectations for board oversight. Enforcement of fraud and abuse laws based on poor quality of care, as well as federal standards for board oversight of healthcare quality and compliance, have set higher standards for board conduct. This article examines the emerging paradigm for board oversight of healthcare quality, and recommends how boards should proceed to meet their responsibilities in an era of comparative quality measures and transparency.