Following the release of its strategic plan, in which patient safety and quality were highlighted as key directions, St. Joseph's Healthcare Hamilton recognized the importance of engaging its board of trustees to achieve these goals. Following a collaborative retreat with senior management, medical staff leadership and professional practice leaders, the board enhanced its governance oversight on quality. By removing quality from the consent agenda, defining quality and selecting a series of "big dot" measures, the board has led the development of a culture of quality that cascades from the boardroom to the bedside. This article describes how the organization followed a systematic process to define quality and select big dot quality indicators.