Procedural sedation is an indispensable component of modern medicine, extending far beyond the operating room into endoscopy, interventional radiology, emergency medicine, and ambulatory settings. This chapter examines the anesthesiologist’s essential role in sedation governance—the oversight, credentialing, and quality assurance that safeguard patient safety and institutional integrity. It outlines the regulatory and accreditation frameworks established by CMS, The Joint Commission, and other governing bodies that define the expectations for safe sedation practice. The chapter details professional guidelines, including the ASA Practice Guidelines for Moderate Procedural Sedation and Analgesia, and explains how anesthesiologists lead in developing institutional policies, training programs, and privileging pathways for non-anesthesiologist providers. Through structured credentialing, simulation-based competency assessments, and continuous data-driven quality improvement, anesthesiologist-led programs reduce adverse events, mitigate liability, and enhance operational efficiency. Finally, the chapter explores the economic and strategic value of effective sedation oversight, including cost avoidance through safety, improved throughput, and institutional reputation. Emerging trends such as AI-assisted monitoring, tele-sedation, and data integration are discussed as future directions. Collectively, the chapter demonstrates how anesthesiologists, as perioperative leaders, extend their influence beyond the OR to define the standards of safe, high-value procedural care across the healthcare continuum.