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.

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.

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.

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.

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.

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.

We asked Zac Watne, Utah’s payment innovation manager (he gets paid to understand the volatile world of payment reform) to give us a primer on “bundles.” Regardless of change happening in health care, thought leaders predict that payment reform, and specifically bundled payments, are here to stay. Why? Bundles deliver care with improved outcomes at a lower price all over the United States. In this post, Zac predicts the future of bundles.

Process mapping is easy. But also hard. This is a common conundrum with value improvement. Here's part 1 of 4, wherein rules are distinguished from guidance.