In a quest to exceed the expectations of our veterans, the staff strives to perform at the highest level of competence in all endeavors. An opportunity to improve nurse-sensitive indicators associated with patient falls was noted. The fall prevention program was evaluated and a plan was formulated. The 5 principle elements incorporated in clinical trials for practice improvement included: collaborative interdisciplinary practice, active leadership engagement, use of technology to support processes, carefully executed communication strategy and house-wide change. As a result of practice improvements at the study facility, positive outcomes were evident. In a national database for hospitals having a similar bed size, the study facility outperformed more than half of others in regard to total falls and falls with injury per 1000 days during two-quarters.