Ventilator-associated pneumonia (VAP) is a preventable secondary consequence of intubation and mechanical ventilation and is the most common nosocomial infection in mechanically ventilated patients (Barclay & Vega, 2005; National Nosocomial Infections Surveillance System, 2000). Summa Health System, a 925-bed, level I trauma center in Akron, OH, embarked on a performance improvement (PI) project to decrease the incidence of VAP as part of The Institute of Healthcare Improvement's (IHI's) Protecting 5 Million Lives campaign. The campaign consists of evidence-based interventions including best practices in several disease processes such as VAP. The groups of interventions are called bundles. The goals of the IHI bundles are to improve treatment of specific disease processes and improve patient outcomes. Summa Health System embraced several of these bundles, the most successful of which was the VAP bundle, which decreased the VAP rate from 4.265% to 0% within 6 months.