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.

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.

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.

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.

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.

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.