A missed diagnosis can delay treatment or result in inappropriate treatment, causing unnecessary pain, suffering, and often financial hardship for our patients. Internist and hospitalist Peter Yarbrough helps explain why diagnostic errors happen with strategies to prevent them.
When health care is designed around patient needs, it doesn't just benefit the patient — it can also help providers find fulfillment in their work. But what does that look like in practice? Physician Joy English opened the Orthopaedic Injury Clinic, an innovative service that delivers better value to patients. Her success is a case study in how to achieve both provider and patient happiness.
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.
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.
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.
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.
To celebrate the New Year, Value Engineer Mitch Cannon applied statistics to weight loss. He was quickly reminded of an important lesson that applies in health care: when you’re trying to improve, don’t overreact to data.
Balancing uncertainty, fear, and emotions isn’t easy — especially in health care. Family practice physician Kyle Bradford Jones looks outside of his practice to identify two common biases that affect how we behave in the face of perceived risk. His key insight? The risk that isn’t directly in front of us may be mistaken for no risk at all.
First came High Reliability Thanksgiving. Then High Reliability Camping. In keeping with the Lean holiday spirit, Accelerate’s Marcie Hopkins shares her method for high reliability gift wrapping — with a little help from our friends in Sterile Processing, who’ve perfected the envelope fold.
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.
