Medical errors often occur due to system failure, not human failure. Hospitalist Kencee Graves helps explain why we need to evaluate medical error from a system standpoint.

Depression is one of those problems so big and so pervasive that tackling it seems impossible. That's why process improvement is so powerful: by setting one goal—improving depression screening rates—11 U of U Health Community Clinics are making the impossible manageable.

Sterile Processing runs a lean operation, and this video produced by value engineer Steve Johnson and video wizard Charlie Ehlert won a national 2018 Telly Award for shedding light on our system’s unseen infection prevention heroes.

Improvement work isn’t easy, especially when it attempts to address rising health care costs. Solid organ transplant coordinator Sharon Ugolini and her team led award-winning work implementing new protocols for common tests. That led to more than just reduced patient charges, though — ordering appropriate tests increases value and quality, as well.

University of Utah Health’s success is driven by teams doing the right work for our patients — and sharing that work across the system. Chief Medical Quality Officer Bob Pendleton reflects on the universal importance of continuous improvement while looking at health care through the eyes of a patient.

A core improvement principle states that the expert is the person doing the work. Utah’s system-wide effort to reduce sepsis puts this principle into action. To adapt to the fast-paced nature of the Emergency Department, an interdisciplinary team used a simple tool: a paper checklist. Clinical nurse coordinator Jamie Troyer and nurse educator Emilie Johnson share how and why the checklist works.

Including patients in treatment planning improves their experience, and patient reported outcomes (PROs) offer new ways to do just that — talking with patients about how treatment impacts their daily life. Clinical Nurse Coordinator Lisa McMurtrey shares the Burn Clinic team’s award-winning work implementing PROs during patient visits without disrupting flow.

Biometric identification is a national best practice — but adapting that to a local environment isn’t easy. Although it’s rare, confusing an identity can have scary consequences (like getting a prescription for a drug you’re allergic to.) So Doug Ostler and his team worked to implement palm scanners and make patients feel safer.

When Amazon, Berkshire Hathaway, and JP Morgan Chase & Co. announced their plans to partner up and tackle “the ballooning costs of health care,” our industry underwent a collective shudder. Thankfully, Utah’s payment innovation manager Zac Watne is back to help us unravel the complexity.

Evidence-based practice (EBP) integrates clinical expertise with the best available evidence to drive innovation and improvement. Sue Childress, director of nursing at Huntsman Cancer Institute, champions the process in advance of the 5th Annual Evidence Based Practice Council Poster Fair.

Kyle Bradford Jones is back, this time with a deep dive into decision-making. Jones uses psychology to explain why it takes so long to adopt new evidence into our clinical practice and argues that we need to actively schedule time together in order to reflect.

Utah's value engineers turn any real-world event into a cause for improvement. Recently, senior value engineer Will McNett and a friend were swept up in an avalanche, traveling 50 yards down the southeast face of Albright Peak in Grand Teton National Park. What many would consider terrifying, Will considered a cause for observation, investigation, analysis, and improvement.