SUCCESS Story: Utah Office of the Medical Examiner

jessicalarsen Newsletters, Success Stories

It is common for people to claim the work they do is “unique” and, as a result, the concepts found in the SUCCESS Framework do not apply to them. Leadership at the Department of Health and the Office of the Medical Examiner (OME) once again demonstrate that everything we do in government can benefit from operational improvements. Read on to learn how OME reduced backlog cases by almost 50% while also improving completion times for current reports.   


OME conducts autopsies and issues death certificates and written reports for individuals who die under violent, suspicious, or other non-natural circumstances. Death certificates and written reports are used by multiple stakeholders for insurance claims, settlements, criminal prosecution and civil litigation, public health research and intervention, organ and tissue donation, and most importantly, feedback to families on the cause and manner of their loved one’s death.

OME’s goal is to provide death certification and examination reports to families and other stakeholders in the timeliest manner possible without affecting quality outcomes. To this end, the office established two performance targets—significantly reduce its incomplete case backlog and substantially increase the percentage of new exam reports completed in less than 60 days.


Utilizing tools and concepts from the SUCCESS Framework, the office removed obstacles that kept pathologists from focusing on their core work, developed and used operational process measures to provide focus and a regular and visual review of case progress, added a monthly review and discussion of cases with all pathologists, implemented distribution of weekly reports to staff to remind them of deadlines, and increased team member accountability for their work.


After applying the strategies above, OME reduced backlog cases by almost 50% while simultaneously improving the percentage of autopsy reports completed in 60 days by 44%. This has resulted in an estimated savings of $4,362 per timely report. But most importantly, individuals suffering loss are receiving faster feedback.

Congratulations to the OME team on the impressive results!