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.

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.

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.

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.

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.

Engineer Cindy Spangler compares canyoneering and surgery and identifies a common thread: the need for high-reliability processes. She describes how surgical time-out, a quick huddle to debrief before surgery, can serve as a useful model for reducing the risk of harm in canyoneering.

Using improvement methodology to solve one piece of America’s opioid epidemic. Dr. Sean Stokes and team used the practice of scoping to focus on one population and one procedure to achieve manageable, measurable improvement.

Improving value in health care means tackling long-standing problems. These problems have seemingly simple solutions, but just won’t stay fixed. Fixing the old problems of health care requires new problem solving skills. Nurse manager Jamie D’Ausilio used University of Utah Health’s value improvement methodology to confront one of the most common management challenges—unnecessary overtime. Using concepts from lean and six sigma, D’Ausilio identified waste, prioritized root causes, and engaged her team to design interventions to create new workflow design.

When a mistake happens, we promise we will never let it happen again. The problem is that a personal vow doesn’t change the way the system operates. Value engineers Steve Johnson, Cindy Spangler and Will McNett look at common personal incident—backing into the lamppost in your own front yard—as a lens for eliminating risk.

Just under 40,000 pieces of physical equipment keep our hospital system humming—everything from hospital beds to air chillers. Casey Chandler manages the team that takes care of all 40,000 items. Here, he details the tools that keep us safe.