Ventilator Associated Pneumonia (VAP) is the second most common hospital-acquired infection. We spent a lot of time in the gemba, on floors with ventilated patients. We learned that oral care kits were difficult to use, they were loud, you had to pull them apart, and there was no clear indication if someone else had already performed the oral care. So we re-thought the structure and made it like a Pez dispenser. You pull the bottom one out with a little finger-notch and the next in line falls in place for next time. This intuitive approach to packaging makes it easier to stay on track with oral care protocols.