Develop action plan : The Maryland Hospital Acquired Conditions (MHAC) for CY16 Q3 was 0.81, exceeding the goal of greater than 0.47 for CY16, indicating fewer hospital-acquired conditions than the minimum standard.Hospital-acquired Infections (HAIs) for December CYTD were as follows: C.diff 0.5 against a goal of less than 0.79 for CY16, indicating successful control of C.diff infections. CLABSI was zero against a goal of less than 0.369 for CY16, showing very effective control measures for CLABSI. However, CAUTI were at 1.28 against a goal of less than 0.906 for CY16, indicating a higher than acceptable rate of CAUTI infections. MRSA infections were at 0.29 against a goal of less than 0.767, showing effective control of MRSA infections