Discussions of hospital quality, cost control, and hospital nursing care have often taken place independent of one another. These discussions need to be integrated, and the goals of assuring the adequacy and performance of hospital nursing, improving quality, and achieving effective cost control need to be harmonized. In this paper we argue, first, that the staffing and organization of hospital nursing affects both quality and cost; second, that nurses must be actively involved in process improvement directed at both quality and efficiency; and third, that there are emerging models of how such engagement can be obtained from both the hospital-level leadership and the front-line staff.