Background Physicians should be engaged in quality-improvement activities to make the systems in which they work safer and more reliable. However, many physicians are still unable to contribute to patient safety initiatives that lead to safer, high-quality care for their patients.

Objective To survey 10 high-performing hospitals in the USA to determine how they engage their physicians in quality and safety.

Design Qualitative study that used site visits and a semistructured 20-question interview.

Setting Ten high-performing US hospitals were chosen from the 2010 US News and World Report Best Hospitals and the Leapfrog Group on Patient Safety.

Participants Forty two interviews were conducted with forty-six quality leaders including CEO's, Chief Medical Officers, Vice Presidents for Quality and Safety and physicians.

Measurements Site visits and in-person interviews were conducted during 2010–2011. The interviews were transcribed and coded using the constant comparative method for further analysis by the team.

Results The authors developed a six-point framework for physician engagement in quality and safety as a constellation of the best strategies being used across the country. The framework consists of engaged leadership, a physician compact, appropriate compensation, realignment of financial incentives, data plus enablers and promotion.

Limitation The qualitative design and the small number of hospitals surveyed mean that the results may not be generalisable.

Conclusion There remain many ongoing barriers to physician engagement in quality and safety. Some high-performing hospitals in the USA have made significant improvements in engaging their physicians in quality and safety. The proposed framework can assist organisations in the development of strategies to engage physicians in quality-and-safety activities.