The purpose of this monograph is to construct a package of proposals which will allow an NHS Board to achieve improvements in the delivery of patient care and implement its clinical governance responsibilities. Prepared with a specific Board in mind, the recommendations will be relevant to all clinical organisations in Scotland at Trust and NHS Board level. The introduction sets out the study and the context for the monograph. The study started with the key principles relating to clinical quality outlined in 'Designed to Care' (The Scottish Office Health Department, 1997) and the 'Scottish Health Plan' (The Scottish Executive Health Department, 2000) and reinforced in other associated documents. It examined international writing on improving clinical quality and on the nature of governance arrangements. It examined whether it is possible to establish a baseline within the system in terms of clinical quality and examined what now needs to be done to ensure that, as Chief Executive of the NHS Board, accountabilities can be delivered. It also looked at the method by which the NHS Board can best deliver its responsibilities in relation to governance in this area. A model for progressing this within an NHS Board has been constructed and an action plan showing how this can be implemented will be prepared. It is envisaged that the action plan will have to be implemented over a medium-term time scale of 12-18 months. Clinical quality of service and governance arrangements are in them- selves different issues - either can exist alone. However, unless they fit together, with governance arrangements focussed appropriately, then this system of working will not lead to any improvement; indeed it will detract attention from the real issues of the day, and no assurance will be achieved. The challenges around implementing the new governance arrangements were central to this monograph and before looking at how this could be effectively done, it was necessary to understand the reasons behind the importance of this accountability within the Scottish NHS in further detail.