Abstract

This dissertation reports the results of analyzing the possible failures in medical test ordering and delivery (MTOD) systems within McGill University Health Center (MUHC) in Quebec. In conjunction with an external consultant and the Fédération des médecins spécialistes du Québec, we have mapped the daily test ordering and delivery process of several medical departments within this hospital. All sessions were video‑recorded, fully transcribed, and iteratively coded. Each transcript was decomposed into discrete task
blocks from which individual SIPOC diagrams were prepared. Read side‑by‑side, the SIPOCs exposed hidden hand‑off gaps and bottlenecks. For every high‑risk step a Failure‑Mode‑and‑Effects‑Analysis (FMEA) table was created. The combined SIPOC & FMEA guided the sprint that produced a patient‑facing pilot application: a stand‑alone layer that sits beside OACIS, neutralizing the three most‑frequent failure modes, poor communication
of test results, missed bookings, and bookings that were never created. Preliminary analysis indicates that integrating SIPOC mapping and FMEA within a user‑centered design workflow streamlined decision‑making and enabled rapid prototyping of the pilot MTOD application. However, additional validation is needed before any claims about risk reduction or clinical impact can be made.