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Leading change. Harvard Business Press; 1996. Kotter\u2019s eight-step model is used to manage change across a wide variety of organizations and industries. The eight steps of change occur in three phases: (a) establishing optimal conditions for change; (b) enabling the organization for change and empowering individuals for change; and (c) implementing and sustaining change. In Table 1, an example plan is given using the Kotter model."},{"issue":"22","key":"638_CR2","doi-asserted-by":"publisher","first-page":"2039","DOI":"10.1001\/jamainternmed.2013.9763","volume":"173","author":"E Zimlichman","year":"2013","unstructured":"\u2022\u2022 Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health care\u2013associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039\u201346. Zimlichman and his colleagues provide an estimation of healthcare costs attributed to hospital-acquired infections in the USA using data from years 1986 through 2013. Major findings include (a) central line-associated bloodstream infections are the most expensive per-case hospital-acquired infections; (b) the total annual cost for the five major infections is approximately $9.8 billion; and (c) surgical site infections contribute the most to total hospital-acquired infection treatment cost at 33.7%.","journal-title":"JAMA Intern Med"},{"key":"638_CR3","unstructured":"\u2022 Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Commissioned by the Centers for Disease Control and Prevention in 2009, Economist R. Douglas Scott reports on the economic impact of treating and preventing hospital-acquired infections in the USA. The overall annual direct medical costs of hospital-acquired infection treatment was estimated at $28.4 to $33.8 billion (using consumer price index for all urban consumers) and $35.7 billion to $45 billion (using consumer price index for inpatient hospital services). The benefits of hospital-acquired infection prevention are estimated at a low to be $5.7 to $6.8 billion (20% of infections preventable, consumer price index for all urban consumers) and at a high to be $25.0 to $31.5 billion (70% of infections preventable, consumer price index for inpatient hospital services)."},{"issue":"1","key":"638_CR4","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1007\/s11606-015-3567-0","volume":"31","author":"KK Kondo","year":"2016","unstructured":"Kondo KK, Damberg CL, Mendelson A, Motu\u2019apuaka M, Freeman M, O\u2019Neil M, et al. Implementation processes and pay for performance in healthcare: a systematic review. 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JAMA Intern Med. 2015;175(3):347\u201354. This reference outlines effects of Medicare\u2019s financial penalties for hospital-acquired conditions. For conditions with strong evidence-based guidelines available (including central line-associated bloodstream infections and catheter-associated urinary tract infections) nonpayment is associated with improving trends.","journal-title":"JAMA Intern Med"},{"issue":"3","key":"638_CR8","doi-asserted-by":"publisher","first-page":"137","DOI":"10.3961\/jpmph.2012.45.3.137","volume":"45","author":"JY Lee","year":"2012","unstructured":"Lee JY, Lee SI, Jo MW. Lessons from healthcare providers\u2019 attitudes toward pay-for-performance: what should purchasers consider in designing and implementing a successful program? 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