Every year the Exceptional Value Annual Report documents the performance of University of Utah Health on all 45 of the key initiatives identified in the organization's Operational Plan. Focused on value-driven outcomes (quality, service and cost), our successes are celebrated and failures are reviewed for learning opportunities.

1. EXCEPTIONAL ALUE
VA N N U A L R E P O R T
F Y 2 0 1 6

2. 1
Table of Contents
Patient Experience .......................................................................................................................................... 5
1. Improve Patient Access.......................................................................................................................... 6
2. Enhance Patient Communication......................................................................................................... 10
3. Improve Transitions of Care.................................................................................................................. 11
4. Improve the Clinic Visit Experience...................................................................................................... 12
5. Improve HCAHPS Performance............................................................................................................ 13
Quality............................................................................................................................................................14
1. Improve Quality Care............................................................................................................................. 15
2. Optimize Epic Care ................................................................................................................................ 16
3. Improve Patient Safety.......................................................................................................................... 17
5. Continued Implementation of Exceptional Value Initiative................................................................. 19
Financial Strength.........................................................................................................................................24
1. Grow Clinical Services........................................................................................................................... 25
2. Increase Capture Rate of Internal Referrals ........................................................................................ 27
4. Expand and Strengthen Network Affiliations....................................................................................... 28

3. 2
How does University of Utah Health Care improve
the value of care we deliver to our patients?
We integrate the best principles, methods and
structures drawn from other highly successful
industries around the world. To name a few,
these include the standards designed by the
International Organization of Standardization,
ISO 9001, process improvement methods drawn
from lean/Six Sigma/PDCA, world class data and
analytic platforms, and safety science methods.
Collectively put together in a way that is uniquely
“Utah”, we call the adoption of these principles,
controls and structures our Value Management
System.
Our Value Management System is based on
seven principles:
1. Focus on the patient. In addition to building
a system and culture that ensures safety to our
patients, we systematically gather feedback from
our patients to understand their current and future
requirements and expectations and we rigorously
assess the outcomes and costs of individual patient
care. We then constantly seek to improve the value
of care we provide our patients.
2. Provide leadership to the organization.
Our leaders at all levels establish unity of purpose.
Leaders ensure that all strategies, policies,
processes and resources are aligned to pursue
common direction and achieve common objectives.
3. Engage and involve people. We have built an
organization of competent people who we manage
through empowerment; engaging their expertise and
effort to improve the organization and recognizing
their achievements and contributions.
4. Use a process approach. We use a process
approach to manage our performance. This means
that our leaders manage and control their processes,
the interactions between these processes, and the
inputs and outputs that tie these processes together.
This also means that we manage these processes
as a coherent value management system.
5. Encourage improvement. We focus on and
promote improvement. We know that improvement
is essential to maintain our current levels of
performance, respond to a rapidly changing external
environment, and to identify, create and succeed in
new opportunities.
6. Make data driven decisions. We make
decisions using data. We know our decisions
are data driven when we gather multiple types
of input from multiple sources, identify facts,
objectively analyze data, examine cause and effect
relationships, and consider potential unintended
consequences.
7. Manage our organizational relationships.
We carefully manage relationships with our
suppliers, partners and other interested parties.
These relationships can influence our performance
and either undermine or strengthen our success.

4. 3
For the past nine years, the organization has
had the discipline to focus on three institutional
goals: exceptional patient experience, quality and
financial strength. In FY2016 University of Utah
Health Care achieved greater overall success
in these areas than any year prior. This year,
University of Utah Healthcare also received its
ISO 9001 certification from DNV. FY2016 truly
has been a significant year for UUHC and our
patients. We are humbled by the contribution and
commitment of all the UUHC physicians, leaders
and employees.
After six years of being recognized in the Top 10
academic medical centers for quality, UUHC was
recognized as #1 in Quality through the Vizient
Quality and Accountability Award.
80
81
82
83
84
85
Q4FY16Q3FY16Q2FY16Q1FY16
82 82
83
85
Medical Practice Overall Ranking
Press Ganey UHC Benchmarking
Percentile
Exceptional Patient Experience. We have
maintained and improved upon our long history
of delivering and exceeding our patient’s
expectations. For the first time this year, the
system’s overall patient experience performed
above the 80 %tile all
four quarters when
compared against
our academic peers.
We are especially
proud that we were
able to reach 85%tile
performance for the
fourth quarters

5. 4
0
2
4
6
8
10
12
FY16FY15FY14FY13FY12
OperatingMargin
5.4%
4.7% 4.8%
10.3% 10.0%
The road to sustained improvement and forward
looking innovation is paved with the ability
to relentlessly focus on the most important
work. Such focus has led to the success and
accomplishments of the past decade and most
specifically the success of the past year. The
purpose of this report is to share the great
work of all of our teams and the contribution of
those teams to the organization’s success. It
documents the outcomes that the organization
has achieved through the declared focus of
the Operational Plan. We thank you for your
And FY2016 was the most significant financial
year for the system ever, with the financial
performance of UUMG, SOM departments and
hospitals and clinics exceeding expectations.
commitment to making UUHC one of the best
academic medical centers in the country. Even
more importantly, we thank you for your profound
impact on the lives and health of our family
members, neighbors and community.
Bob Pendleton
Chief Medical Quality Officer
University of Utah Hospitals and Clinics
Dan Lundergan
Interim Chief Operating Officer
University of Utah Hospitals and Clinics
Dayle Benson
Executive Director
University of Utah Medical Group

6. 5
Patient Experience

7. 6
1. Improve Patient Access
Increase the number of new patient visits by 5%.
New Patient Visits
FY 2013 180,517
FY 2014 195,247
FY 2015 212,525
FY 2016 242,011
How do we make it easier for our patients to come here? A seemingly simple question – but improving access
has required both a system focus and local innovation.
System Achievements:
• We increased new patient visits by 13.87% from FY15. This has required us to sustain the gains of the past four years,
with additional incremental growth.
• We established standards and measures of access performance across the system.
• We maximized our EPIC scheduling system through standard training for all staff.

8. 7
Extend hours of clinic availability across the system (10% of clinics will
have availability from 7 am to 7 pm).

9. 8
Achieve overall 50th percentile for ease of new patient scheduling by
the fourth quarter.

10. 9
Expand Urgent Care capacity to 5 sites by the end of the FY.
NumerofVisits
Urgent Care is spreading across the Wasatch Front in order to improve access to appropriate, higher
value care where the demand is greatest. Quarterly urgent care visits have continued to expand,
nearly doubling between Q1FY16 and Q3FY16. Urgent Care added two additional locations in
FY2016, Westridge Health Center and the University of Utah Hospital.

11. 10
2. Enhance Patient Communication
Reduce No-Show Rates by 10% (i.e. text, email, etc.).
This effort was gated for FY2015 due to contingent projects on template optimization, guest
communications center and online scheduling.

12. 11
Develop a post-acute care strategy that meets our quality standards
and supports future reductions in hospital readmissions.
3. Improve Transitions of Care

13. 12
4. Improve the Clinic Visit Experience
Achieve overall 70th percentile for “wait time in clinic” for 2 quarters.
Develop a patient friendly process to share pricing for imaging services
and ambulatory procedures by the third quarter FY15.
Pricing Strategy: The pricing estimator process went live September 1, 2016.
• Price Estimates are calculated in EPIC, for hospital and physicians, in a combined output.
• 3,000 price estimates are given per month
• Three primary categories of patients call for estimates: cosmetic, shoppers and existing patients.
• 80% of UUHC departments use central financial counseling and the EPIC tool.
• 18 specialties currently publish prices on their webpage.

14. 13
5. Improve HCAHPS Performance
60th percentile pain management
60th percentile MD communication
60th percentile nurse communication
Lessons learned:
RN Communication: Focus on Process
• Develop a reliable process approach to
communication: Bedside Shift Report (BSR)
• Engage frontline staff: EPIC workflow does not
support current BSR approach
• Redesign EPIC workflow to promote more efficient and
integrated document and record control
MD Communication: Voice of Customer
• Patients who know the doctor in charge of their care
are more likely to rate communication as meeting
expectations.
• Use of whiteboards to communicate
Pain Management: Misaligned focus
• Focus on always managing pain conflicting with state
and national focus to reduce opioid dependency.
Despite not meeting FY16
goals, there has been
incremental improvement
over the pas t4 years.

15. 14
Quality

16. 15
1. Improve Quality Care
2016 AMC Quality and
Accountability Performance
Scorecard
2016 Ambulatory Quality and
Accountability Performance
Scorecard
Univsersity of Utah Hospitals and Clinics University of Utah Health Care and
University of Utah Medical Group

17. 16
2. Optimize Epic Care
Implement nurse triage module.

18. 17
3. Improve Patient Safety
Reduce/maintain hospital acquired infections (ICU CLABSI, ICU CAUTI,
and SSI) from FY14 baseline to a Standardized Infection Rate (SIR) of
<= 0.5 CLABSI, <= 1.0 CAUTI and <= 1.5 SSI by January 2016.
CAUTI
ICU YTD SIR
CLABSI
ICU YTD SIR
FY16 Q1 0.746 0.368
FY16 Q2 0.519 0.299
FY16 Q3 0.833 0.274
FY16 Q4 0.957 0.286
An interdisciplinary team developed a
comprehensive protocol of standardized best
practices for management of urinary catheters
(2535 views on Pulse). They also developed
standardized clinical skills and created a nurse-
driven catheter removal process. The team
updated EPIC to document standardized care.
Throughout FY16,
baseline investigation and
subsequent improvements
in processes to reduce SSI
were actively implemented
by an interdisciplinary team.
SSI
Overall SIR
FY16 Q1 1.99
FY16 Q2 1.79
FY16 Q3 2.00
FY16 Q4 1.76

19. 18
4. Fully Implement the Value Management System
in Order to Meet Accreditation Requirements of
Being ISO-9001 Compliant

20. 19
5. Continued Implementation of Exceptional Value
Initiative
Implement 10 value-driven care processes with a goal impact of
measurably improved quality and $5M cost savings.
$8.7 Million Savings

21. 20
Sepsis Project
0
$
$$
$$$
$$$$
$$$$$ no
yes*
Aug 2016Jul 2016Jun 2016May 2016Apr 2016Mar 2016Feb 2016Jan 2016Dec 2015Nov 2015Oct 2015
*Perfect Care was achieved if the following occured within 180 minutes:
 Lactate lab
 Blood culture
 Antibiotics
 IV fluid
Sepsis (mEWS>5) Mean Cost Per Case and Perfect Care

22. 21
UHPP Initiatives
Annual System Savings
0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
TRANSPLANTPULMONARYPM&RPEDIATRICS
ORTHO / NEUROSURGERYONCOLOGYOBGYNNEUROSURGERY
NEUROLOGYGENERAL SURGERYGENERAL IMCARDIOVASCULARANESTHESIOLOGY
201620152014201320122011

23. 22
Supply Chain - Standardizing Supplies
Cumulative System Savings
0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
CAPITALPURCHASED SVCSSUPPLY OTHERORTHOPEDICS
OR GENERALNEUROSCIENCESIMAGINGENDOSCOPYCARDIOVASCULAR
FY16FY15FY14FY13FY12

24. 23
Identify and develop Value Driven Outcomes (VDO) scorecards for 15
top clinical conditions.

25. 24
Financial Strength

26. 25
1. Grow Clinical Services
Increase outreach clinical services outside the Wasatch Front by 5 sites,
which could include virtual TeleHealth.
TeleHealth Sites Location Services
Forte Strong St. George, UT Mental Health
Four Corners Regional Care Center Blanding, UT
Physical Medicine
and Rehabilitation
Green River Medical Center Green River, UT Burn
Learning Services Corporation Riverton, UT
Physical Medicine
and Rehabilitation
Lost Rivers Medical Center Arco, ID Burn and ICU
Power County Hospital District American Falls, ID Burn
Southwest Counseling Center Rock Springs, WY Mental Health
Steele Memorial Medical Center Salmon, ID Burn

27. 26
Increase inpatient referrals from targeted regions by 5% over prior two
year baseline.
Overall
Growth
5%
increase
in cases
13%
increase
in margins

28. 27
Increase pharmacy prescription capture rate by 25% from the UUHC
clinics FY14 baseline.
2. Increase Capture Rate of Internal Referrals
3 Month Rolling Average
Single Month Totals
11.75% Increase
9.7% Increase
At the end of: June 2015 June 2016
Scripts Ordered 55,114 61,225
Scripts Filled 18,822 21,034
% Scripts Filled 34.15% 34.35%
At the end of: June 2015 June 2016
Scripts Ordered 55,136 60,495
Scripts Filled 18,667 20,479
% Scripts Filled 33.86% 33.85%

29. 28
4. Expand and Strengthen Network Affiliations
Implement Epic Connect with 2 entities.
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02/22
Go LiveImplentationPlanning
Community Clinic 3
Community Clinic 2
Community Clinic 1
Hospital 4
Critical Access Hospital 2
Critical Access Hospital 1
Hospital 3
Hospital 2
Hospital 1