Therapeutic, technological, and medical advances have contributed to improve Infant Mortality Rates in the United States over the last 100 years. However, there are still geographical and racial disparities and challenges, and infant mortality remains higher in the Unites States than in many other developed countries. A formal death review process can identify causal, contributory and potentiating factors related to infant deaths. This article describes use of the PDSA Model for Improvement to develop a strategy for change that will result in reducing the Infant Mortality Rate within an organization.