We used a sociotechnical systems analysis to improve the diagnostic testing process in one Midwestern health care organization's outpatient clinics. Outpatient clinic personnel from the clinic were interviewed about their role in the diagnostic testing process. Information on process variances was also collected. A variance matrix and a key variance control chart were constructed for the variances reported by the clinics. Key variances found in the clinic included sample misplaced, sample mislabeled, sample not delivered, sample damaged, request form problems, result tracking breakdown, slow result delivery, result never seen, and patient notification. Based on the variances found in the clinic, recommendations for improvement are given.
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