Ventilator-Associated Pneumonia (VAP) is the leading cause of death associated with healthcare-associated infections (HAIs) (IHI, 2012). With 300,000 cases of VAP annually in the U.S., this preventable illness is estimated to cost $50,000 per patient (Fraser et al., 2008). In addition to being the second most common nosocomial infection worldwide, VAP is the most life threatening (Timsit et al., 2017). Prevention of VAP is inexpensive and could save up to $1.5 billion per year (Scott, 2009). Although VAP does not represent the majority of pneumonia cases, those on a ventilator are most at risk for developing the infection (Magill et al., 2014).

Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.

Actionable steps include:

• Executive Summary Checklist
• Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
• Performance improvement plan to follow if improvements are necessary
• Clinical workflow for preoccupation with workflow for areas of improvement
• How to educate patients and family members about the significance of their role throughout the continuum
• Guidance on how to measure outcomes