Making quality improvement changes in the healthcare field are difficult. Making the changes stick is even harder! Consider, if you would, some change at your site that made a vast improvement in quality. Time was saved, patient care improved, and the bottom line improved. Now, look back, is that change still in place? Sadly, after some time has passed, many positive changes disappear. Why? We slip back into old habits. They are hard to shake. What personal habits have you tried to change? Was it hard? Habits in an organization are just as hard to change, if not harder, since more people are involved. Another reason your site changes didn