Scope is a powerful tool when changing practice. Rather than trying to revamp in one large swoop, scoping an improvement down to palatable stages can overcome resistance and lead to meaningful results for future improvement cycles. Although new improvers may feel this approach delays impact, repeated improvement cycles often lead to sustained care transformation. Dr. Theophilus Owan demonstrated this principle in his quest to improve value by standardizing anti-thrombotic medications given to patients undergoing percutaneous coronary intervention (PCI).

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.

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.

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.

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.

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.

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.

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.

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.

The dojo welcomes guest author and senior value engineer Will McNett with a deep dive into clinic capacity utilization. McNett borrows from manufacturing to offer a framework to measure and increase what really matters to patients: time spent with their provider.