Process improvement attempts, in the absence of focused process investigation and accurate documentation, are frequently an effort in futility. Most health care workers can recount at least one tale of the phenomenon that occurs as a result of the efforts of well-intentioned employees who invest time, resources, and energy to remedy problems. These efforts repeatedly produce unpredictable and undesirable results, which become apparent as the downstream effects emerge. Initial improvements may be obtained, albeit the success is frequently transient and the results unsustainable.