The Institute of Medicine$$s $$To Err Is Human$$ report of

$2000$ estimated that nearly $100,000$ deaths each year in the

United States are caused by medical errors. Many hospitals

are working to change that by employing certified quality

engineers $($CQEs$)$ to apply quality tools and techniques to a

wide variety of issues. This case describes one of those hospitals.

In $2007,$ this hospital saw $350,000$ patients, many

of whom visited multiple times, for an overall total of $1\mathrm{.}8$

million patient encounters. Though this hospital has an excellent

reputation for patient care, leadership has identified

a need to make improvements. The certified quality engineers

study a variety of areas including the physical layout

of the hospital, its treatment rooms, and operating rooms.

They assess operational efficiency and effectiveness. They

study patient throughput and infection rates