According to the CDC (Center for Disease Control), hospital acquired pneumonia occurs in 0.5% - 1% of admitted patients, representing 10 -15% of all nosocomial infections; pneumonia is the most common cause of nosocomial infections in the ICU's. VAP is the leading cause of death among hospital-acquired infections. Project goal was to develop a collaborative, multidisciplinary approach incorporating many interventions that are results oriented, aimed at reducing harm, and have a cost avoidance outcome in critical care areas. Identify the knowledge deficit: Use of the ventilator bundle elements to prevent ventilator associated pneumonia on the part of the Critical Care RN's and Respiratory Therapists. Grow a sense of ownership among the team. Also improve communication between disciplines when implementing sedation vacations and weaning protocols. Oral care and preventative measures on high risk patients needed to become a priority for every patient every time. Goal is to reduce patient harm from VAP by event and rate, aiming for zero.