Designing the Health System that Flows Chasing Results – Eliminating Paper Waste

John Macrow Business Improvement Consultant, Service Redesign Unit, The Royal Children’s Hospital, Melbourne

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BackgroundEvery day at RCH, clinicians order thousands of Pathology and Medical Imaging tests for RCH patients. The corre-sponding paper reports were printed and delivered to all areas of the Hospital, and then the loose sheets of paper were sent to Health Information Services (HIS) for filing. It was unknown how many clinicians actively chased test results using the existing electronic clinical viewer (CLARA system), and did not need the paper copy.

What did RCH do?The project objective was to reduce the many forms of waste associated with printing, sorting, transporting, handling, multiple viewing, and filing of paper in medical records. In order to address these problems, RCH adopted the ‘lean thinking’ approach.

How did RCH do it? Form Steering Committee to examine current

work practices Service Redesign project formalised with

an A3 ‘one-pager’ Survey medical staff and analyse results. Refer Figure 1 Process map Pathology and Medical Imaging referral

processes to the viewing of the results and filing. Refer Figure 3

Implement a Pilot in 3 steps: – Step 1. Stop filing – Step 2. Stop printing in selected wards – Step 3. Stop printing for all inpatient units

Results surveyThe clinical leader sent a survey to all medical staff proposing several models and asking about work practices, concerns, and suggestions. A total of 135 survey results were completed across a wide ‘years since qualified’ demographic, consisting of 54% senior medical staff and 46% junior medical staff. Very positive responses, indicating 82% definitely in favour of a move towards reduced paper reporting.

Viewing results options

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Question to medical sta�: How do you currently access results?

Figure 1: Survey result graph.

* CLARA is Clinical Lookup and Results Acknowledgment and is a web-based software application, allowing staff to view and acknowledge patient Pathology results.

Pilot step 1: Stop filingFiling of results stopped on the 1st July 2008. The visual control was a sticker attached to the medical record folders, stating “Results after 1/7/2008 will be found in CLARA and not in the paper record”. The impact of the change was tracked as shown in Figure 2. One of the enablers for end user engage-ment was the environmental driver to reduce the huge amounts of paper generated by the reports.

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Monthly number of loose documents �led in HIS department 2008/2009

Number of loose documents filed

Before average Clear backlog average After average

Filing stopped

Figure 2: RCH Health Information Services (HIS) filing of loose paper sheets.

Comment: In reference to Figure 2, the clear backlog average step change in July to Sept corresponded to filing only the earlier results. The clearing of this backlog highlights the lag in the system and clearly supports the theory that the most up to date results can only be guaranteed to be seen if one accesses the electronic clinical viewer on a regular basis.

Results: Process changesMapping showed waste in handoffs, and confirmed the need to change. Figure 3 shows the Medical Imaging process where reports were batched daily for couriering to HIS for sorting and filing. The ‘stop’ point represents the change to the process that has been successfully implemented with no complaints.

Medical Imaging Department

Paper resultsprocess

Is it themorning?

At 8.40am 8 to 15 reports printed daily

Reports putin envelopes

Mailed toreferring

doctor

Next clinicianhas paper

result in UR for viewing

At 4.30pm approx 150 to

350 reports printed daily

Reports takento HIS dept. via

internalmail

Results sorted and �led into

medical records

UR folder returned to HIS storage

(for 6 months)

HIS Department

Yes

No

Figure 3: Medical Imaging process flow for results.

Results Significant reduction in HIS medical record costs: a) Need to courier loose sheets b) Need to sort and file c) Storage costs onsite and archiving offsite d) Reduction in space required Reduction in filing of paper by 30,000 sheets per month Reduction in medical record size by 30% Only pathology reports external to RCH are still filed

Pilot step 2: No printing in selected wardsSeveral areas had requested that they not receive any printed reports. An example of duplication waste was in the Intensive Care Unit (ICU). To prevent delays, results are printed on a blood-gas analyser or on ICU ‘trickle’ printers. However, results were still couriered daily and filed at night by ward staff. This selective approach to non-printing was then extended to other areas interested in no longer receiving large bundles of reports every week.

Results No complaints about not having the paper copy Negative comments mostly related to slow PCs in some clinical areas Positive comments from ward staff

Pilot step 3: No printing for ALL inpatientsA way of continuing to provide selective printed copies was needed. Changes to data entry soft-ware and using the existing referral form was a simple cost effective solution. As shown in Figure 4, by actively using the ‘Copy to:’ section allows a paper copy to be sent.

If the “Copy to” box is left blank no report will be printed

Figure 4: Referral form with provision to opt in for a paper copy.

Results No complaints at this stage Existing referral forms unchanged, preventing need for costly revision

Key points Project name ‘Paperless Results’ was changed to ‘Reduced-Paper-

Reporting’ to focus on improvements now, rather than waiting to become a ‘digital’ Hospital

Make the actual process visual for all to see and highlight the process waste

Find a clinical leader to champion the changes Consult all stakeholders from couriers to executive level Identify technical problems early, such as frustrations; software changes Create an online project web page and publish e-newsletters to staff Share successes – Hospital Improvement Committee chaired by CEO

Further work Monitor changes. On track to achieve a goal of ½ Million less paper

sheets per year Enhance CLARA viewing system to ‘push’ results to clinicians Improve computers in outpatient areas prior to stopping their

paper reports Conduct an electronic audit of viewing results to verify adherence Determine project savings, estimated at ¼ Million $ p.a. Scope project on e-order entry of results to remove remaining

waste in process

“Bring it on! We spend huge amounts of time sorting

and filing results that no one has looked at.”

Ward Clerk

“I think the proposal would work as long as

there was an option to request paper copies as

needed. As junior medical staff, very

few of us would ever look at

paper reports.”Registrar

Staff Involved: Steering Committee; Medical Staff; HIS; ICT; Pathology; Medical Imaging; Medico Legal, Service Redesign

http://www.rch.org.au/genmed/staff.cfm?&doc_id=12039

Contact details: john.macrow@rch.org.au

1 John D Macrow, Australia2 John Stanway, Australia 3 Dr Peter McDougall, Australia4 Dr Mike South, Australia