The first thing Maggie did was to put in place the project plan and governance structure. The project sponsors would be the Director of Nursing and the Pharmacist-in-Chief. The core proj- ct team consisted of the two sponsors plus a clinical practice consultant (Nicole) and a knowledge broker (Martha). Many ad loc members-clinicians, experts in process review and evalua ion as well as representatives from different departments, such Quality, Patient Safety, and Performance, Biomed, Finance, ogistics-were solicited as needed for their expertise at differ- ent junctures during the project (see Figure 1)