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.

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.

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.

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.

Is zero possible? In the case of central line infections, the answer was once no. A CLABSI (central line associated blood stream infection) was once considered a car crash, or an expected inevitability of care. When University of Utah’s Burn Trauma Intensive Care Unit started treating CLABSIs like a plane crash, or a tragedy demanding in-depth investigation and cultural change, zero became possible.

Sterile Processing runs a lean operation, delivering millions of instruments to University of Utah Health’s procedural teams. Director of value engineering Steve Johnson, assisted by the video wizardry of Charlie Ehlert, sheds light on our system’s unseen infection prevention heroes.

Follow Utah’s Nutrition Care Services as they produce and deliver over 300 lunches to inpatients all over our hospital, all at the same time. The work of this exceptional team highlights a complex lean operation that—before now—has largely gone unseen.

Chief Medical Officer of Press Ganey Tom Lee reminds us that value does not happen by accident, and good intentions are not enough. The goal of improving value has to be a major focus for everyone in an organization.