1. Work System Analysis

2. 1.Nurse in Neonatal Care draws blood sample from newborn patient who has HIV positive mother. 2.Nurse sends sample to lab processing center. 3.Lab processing center technician forwards blood sample to microbiology lab 4.Microbiology lab technician identifies the numbered sample as a HIV sample and sends it on to the retrovirology lab. 5.Retrovirology lab technician enters patient number information into hospital database. 6.Lab technician performs HIV ELISA screening test when samples meet the capacity of test tray to perform one test, otherwise samples must be preformed within one week. 7.Lab Technician enters patients HIV results into hospital database by patient number. 8.Lab Technician calls the contact Doctor that HIV results are available. 9.Doctor retrieves HIV test results from fax machine and in forms Patients’ Guardian of HIV test Result.

3.  Work System Contains unnecessary hand-offs  Contains too many participants  Customers have unrealistic expectations  Undocumented technology

4. Aspect of performance Metric (specific measure of performance in this situation) Current value of metric Realistic desired value of metric Error Rate% of false positive HIV tests.01%0% Consistency% of all decisions that followed all proper procedures confused 95%99.5% (better training of employees) Participants# of participants required to test and give results of samples 75 SpeedTime from blood draw to HIV test Results 1 week3 days CostCurrent value of work to test samples (confused)

5.  Decrease number of participants  Bypass extra departments  Utilize new technology, database

6.  Change customer expectations  Verify that nurses draw enough blood  Introduce more training for lab technicians  Use labels with bar codes  Bypass extra departments and go directly to retrovirology department  Give doctors access to test result database