 Everybody agrees that we are nowhere near where we ultimately want to get in terms of patient safety here in our hospital and in our country on the planet. Patient Safety Movement Foundation recognized this some seven years ago and laid down one of the highest benchmarks in the safety world which is zero preventable deaths. We have a thousand registered nurses in this hospital and sometimes they would take shortcuts. So we had to put processes and protocols in place ensuring that we're doing the right thing all the time. We looked at these actionable patient safety solutions or apps as they call them. As part of those apps, there is an executive summary and the executive summaries have always included a number of bullet points and we said bullet points are great but they don't always lead to action. We simply said let's make those action items, let's make those boxes and let's do a gap analysis on where we sit in terms of filling those boxes or if we had to color those boxes in a stoplight way like a red, yellow, green where would we be and if we're not where we want to be how do we go about getting there. By creating these guidelines and getting buy-in from all of our providers, we are decreasing variation in care. Evidence shows that those things are really important to prevent infection so they are part of our daily work. And we have expanded that approach now to all of the relevant pediatric apps that exist which is approaching 20. But what the apps did for us was it allowed us to really take a look at well, do comparison of here's where we are, here's where the where what are some recommendations out there, what are our gaps and how do we maybe shore up some of those areas that could lead to potential patient harm. We had zero CLABSIS in the Cardio Vascular Intensive Care Unit for three years and so if you think about what's going on in that unit and how we did that it was because we were standardized and we follow those checklists. We are constantly looking for how to get to zero. You know when we're at zero it's something to be celebrated but it is also a little bit nerve-wracking because if we rest on our laurels there then that's when we're going to be caught off guard. We have an organizational goal that is consistent with the Patient Safety Movement Foundation which is zero preventable deaths. It's nothing, there's no green, red, yellow coloration of that one. It's all or none, you're all in and so getting to zero is the only goal that matters.