Introduction Microsystem Background Virginia Hospital Center’s Labor and Delivery unit, located in Arlington, Virginia, is part of the Mayo Clinic Care Network where more than 4,500 babies are born each year (Virginia Hospital Center [VHC], 2018). VHC manages a 64-bed unit with a family-model approach to maternity care (VHC, 2018). This labor and delivery microsystem includes: obstetric providers, registered nurses, anesthesiologists, obstetric techs, unit secretaries, nursing managers, and the hospital director. The aim of this project is to reduce to incidence of Methicillin-resistant Staphylococcus aureus (MRSA) on VHC’s Labor and Delivery Unit. Labor and Delivery Unit MRSA Problem Approximately one-third of the world’s population colonize the Staphylococcus aureus (S. aureus) bacterium (National Institute of Allergy and Infectious Diseases [NIAID, 2018). One percent of those that colonize S. aureus are diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) (NIAID, 2018). MRSA is found primarily on the skin and nares and is resistant to penicillin-like beta lactam antibiotics (NIAID, 2018). Long-term prescription abuse and overuse of broad spectrum antibiotics is cited as one of the causative factors of MRSA’s resistance to most available drugs (NIAID, 2018). Those that colonize MRSA do not necessarily have an active infection unless the pathogen enters an opening in the skin or mucosa and impacts supporting structures (Centers for Disease Control and Prevention [CDC], 2018). Symptoms of MRSA infection include an erythematous, swollen, painful, warm lesion on the skin (CDC, 2018). The infection can also become systemic and develop into osteomyelitis, endocarditis, pneumonia, or thrombophlebitis (Ventola, 2015). Treating an active MRSA infection is complicated for any patient, but it is especially dangerous for neonates (NIAID, 2018). Neonates are particularly susceptible to MRSA colonization and subsequent infection due to their immature immune system (Ventola, 2015). Unlike adults who have had time to cultivate their immune responses over time, neonates have only been exposed to the semi-allogeneic sterile environment of the mother’s womb (Basha, Surendran, & Pichichero, 2015). After birth, they are thrust into a microbe-filled world with limited physiological ability to exercise their adaptive and innate immune system (Basha, Surendran, & Pichichero, 2015, page 1172). Acquiring early defense mechanisms is a normal progression of development for the neonate, but the danger of antibiotic resistant bacterial infections requires diligence on behalf of the nursing staff….