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.

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.

Improvement in patient experience is often the hardest part of managers’ jobs. It takes consistent work engaging your team. There are no shortcuts. In this occasional series, we’ll be sharing the lessons learned the hard way from people working on the front lines to deliver care. In this post, Urology and Pelvic Care outpatient services manager Leslie Bardsley gives practical advice for involving your entire team in 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.

Value engineer Cindy Spangler has shared her camping and canyoneering expertise with Accelerate in the past. But this winter, her preparation may have done us in: a big purchase of new ski equipment has led to a lackluster snow season. Or has it? Cindy reviews why correlation does not imply causation.

Delivering a great health care experience is only possible with one crucial component: reliable scheduling. It’s such an essential part of efficient operations, in fact, that the University of Utah Health created an access optimization team to help providers across the system.

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.

Dr. Kyle Bradford Jones examines the Netflix algorithm for user preference as a model for developing provider selection tools that match patient values with their care needs.

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.