Improved care processes and patient outcomes were achieved by examining best evidence to guide practice and developing system supports that provided education and improved product accessibility to achieve optimal care. Whereas electronic media for education of health care providers can be challenging,20 creating an online educational program for RNs and CNAs as well as updating hospital policy offered consistent, succinct, and factual content providing an effective medium to improve practice. Re-education about a common nursing intervention (catheter insertion) to ensure that best practice occurred elevated this perceived “simple” skill to a higher level of importance. Expanding the education to ancillary services (eg, rehabilitation professionals and transport staff) helped raise collective awareness of drainage bag location to reduce reflux and CAUTI risks. Product changes that streamlined IUC devices, collection bags, and catheter type (eg, removal of silver alloy catheters) provided an important opportunity for practice improvement and cost savings