The Workflow Map

The Workflow Map

How thinking differently helped Bryan Medical Center uncover simple opportunities
to improve quality.

The impact of compromised quality

This type of story plays out in hospitals all across the country. But when it happened at Bryan Medical Center, the lab’s quality management team started thinking differently.

Situation: In October 2016, a patient came in to receive a CT scan. Routine point-of-care (POC) tests were run, and the CT tech was alarmed to see that the patient had elevated creatinine. 

Result: The tech alerted the physician, who promptly cancelled the CT scan and admitted the patient. A nephrologist was brought in to consult. The patient spent 2 stressful—not to mention expensive—days in the hospital being seen by clinicians and having various tests run.

Article highlights:

  • Workflow maps are a well-tested LEAN tool that helps you uncover potential issues and simple countermeasures that lower risk.

  • The mapping process involves gathering the team, documenting the process, calling out potential issues, categorizing risks, and creating a plan.

  • The benefits of mapping include avoiding unnecessary tests, better patient satisfaction rating, and generating a positive reputation for you lab.

Contributing Lab Leaders

Christina Nickel

Christina P. Nickel, MHA, MLS(ASCP) CM, CPHQ

Laboratory Quality Manager

Bryan Health, Lincoln, NE


Challenging the checklist mentality

Risk assessment of this particular test had been completed for the IQCP requirement in 2016, however, a change in outpatient processes had not been communicated, evaluated or reflected in the IQCP. Christina Nickel’s mentality: “You don’t invest in quality and risk prevention because of regulations. You do it because quality pays off.”

Ms. Nickel is the Laboratory Quality Manager at Bryan Medical Center in Lincoln, Nebraska. Today, she and her team are systematically taking on risk assessment and action plans for all the appropriate tests run in her institution. They have a method that has been highly effective at identifying potential issues and delivering simple solutions to prevent them before they occur.


The workflow map

“Laboratorians are scientists. Drawing out a visual representation of the process helps them think about the process differently.”

Ms. Nickel and her team have been rolling out IQCP-A3 plans to improve quality and avoid situations like the one mentioned above. At the heart of this process is the Workflow Map.

The Workflow Map is a well-tested tool of the LEAN process that involves physically drawing out every step of the test process from pre-analytical through post-analytical. With stick figures and arrows, the Workflow Map identifies every person, device, transfer point, storage condition and more. Every single step is meticulously detailed.

"Changes happen pretty quickly, and it can have a big impact on patient care."

Once the process is mapped, the group looks at each individual step and asks: “What could go wrong?” Every chance of mislabeling, sample compromise and unforeseen error is called out.

“When we look at the same thing every day, we become blind to problems. This process has done a great job identifying those opportunities for failure.”

The Workflow Map process is an effective tool for uncovering potential issues, but that is not its greatest value. It has a remarkable ability to uncover simple countermeasures that can eliminate these risks before quality ever gets a chance to break down. It is a simple tool that delivers enormous benefits.


Get mapping 

Today’s laboratory professionals can’t sit back and be confident in the quality of their lab results. They need to get ahead of errors and actively work to prevent problems BEFORE they occur. The Workflow Map process is easy to employ and is well worth the investment.

Bryan Medical Center’s
workflow mapping process

Gather the team

Make sure they come prepared with copies of the written procedure for the test you’re going to discuss

Bring ALL the people involved in the process

Bring someone NOT involved in the process to provide an objective perspective

Draw out the process step by step

Get granular and list out each step, each device, each transfer…everything

Get the process validated by the people who do it—you will be surprised how many assumptions people make. Be sure you solidify what ACTUALLY happens

Call out the “stormclouds”

Put a “stormcloud” burst around areas where potential issues can occur

Think beyond normal circumstances. Address crazy, unforeseen, worst-case circumstances and you will find areas of unexpected vulnerability

Categorize the risks

Break down all the areas of risk into five categories:

• Testing personnel • Specimen 

• Testing environment • Reagents

• Test systems

Score each risk factor (1-5) based on the following three categories:

• Risk of occurring

• Risk it will cause harm

• Chance to identify the error before it causes harm

Create a plan

List the countermeasures (most of them simple) to the risks you have identified

When you train your staff on the new process, be sure to explain WHY you are putting this new procedure in place

Repeat this process
for every appropriate test
that the institution runs


Why go above and beyond regulations to ensure quality? Consider the potential cost of a single error.


For additional insights and tools, watch the video below to see Christina's presentation on this topic, delivered at CLMA's Knowledge Lab 2017.


Review additional questions and answers from Christina's presentation below:


When you receive a current condition map, what is your process for follow up?

Response: All of the maps are created collaboratively between the Laboratory Specialist who oversees the area and myself. As the Specialist goes through the step-by-step process, I ask TONS of questions (could X, Y, Z happen?). Each of those “opportunities” for errors / failures are evaluated for a risk score and countermeasures are implemented to reduce the risk overall. For example, if you have a risk score that is high on initial assessment, but you implement a method that will allow you to catch it without fail before it gets to the patient, you’ve significantly reduced the risk. Once the process is complete, you ensure that all countermeasures are implemented and re-evaluate at six months, or earlier if another event occurs. We assign a scoring system with some risk scores requiring a countermeasure, however, we routinely assign countermeasures regardless of the score. We do include countermeasures already in place as well.

How do you pick which quality processes to change? What gets priority?

Response: Those processes with the highest risk for error / harm are addressed first. For example, when we started working through our IQCPs, we looked at those that had the highest impact on clinical care, meaning those that our clinicians treat specifically based upon those test results. One example might be evaluating POCT devices / tests used for Codes and Rapid Responses – those would definitely have a higher risk / priority than a C. diff test. Our goal is to evaluate every process for risk and implement countermeasures, but we started with our tests that require IQCP and then have been working on those with a high risk factor and those which have had a near miss or a failure reported, which obviously take priority.

Additional resources


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