1. 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
Background
Pilot step 1: Stop filing
Every day at RCH, clinicians order thousands of Pathology
and Medical Imaging tests for RCH patients. The corresponding 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.
Filing 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 engagement was the environmental driver to reduce the huge amounts of paper
generated by the reports.
Monthly number of loose documents filed
in HIS department 2008/2009
 complaints about not having the paper copy
No

Negative comments mostly related to slow PCs in some clinical areas

Positive comments from ward staff
30,000
20,000
Pilot step 3: No printing
for ALL inpatients
10,000
Fe
b
n
Ja
No
v
De
c
t
Oc
p
Se
Au
g
l
Ju
n
Ju
ay
Month
Number of loose documents filed
Before average
Clear backlog average
After average
The 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.
If the “Copy to” box is left blank
no report will be printed
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 changes
Mapping 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.
Question to medical staff:
How do you currently access results?
Medical Imaging Department
60
55
Paper results
process
48
Is it the
morning?
Yes
At 8.40am
8 to 15 reports
printed daily
Reports put
in envelopes
Mailed to
referring
doctor
No
Number
40
30
26
20
At 4.30pm
approx 150 to
350 reports
printed daily
10
3
3
Reports taken
to HIS dept. via
internal
mail
Results sorted
and filed into
medical
records
UR folder
returned to
HIS storage
(for 6 months)
Next clinician
has paper
result in UR
for viewing
HIS Department
er
ap
os
tly
p
ro
nly
M
pe
Figure 3: Medical Imaging process flow for results.
ix
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Pa
pe
A
r
CL
AR
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on
AR
A
CL
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ly
0
CL
A way of continuing to provide selective printed
copies was needed. Changes to data entry software 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.
Figure 2: RCH Health Information Services (HIS) filing of loose paper sheets.
Results survey
50
M
r
Ap
ar
M
Fe
b
0
n

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
40,000
Ja
How did RCH do it?
50,000
Number of documents
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.
Filing stopped
Several 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
“Bring it on! We spend huge
were still couriered daily and filed
amounts of time sorting
at night by ward staff. This selective
approach to non-printing was then
and filing results that
extended to other areas interested
no one has looked at.”
in no longer receiving large
Ward Clerk
bundles of reports every week.
Eq
ua
l
m
Results
Viewing results options
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.

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
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
“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
Figure 4: Referral form with provision to opt in for a paper copy.
Results
 complaints at this stage
No

Existing referral forms unchanged, preventing need for costly revision
Key points

Project name ‘Paperless Results’ was changed to ‘Reduced-PaperReporting’ 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
1
2
3
4
John D Macrow, Australia
John Stanway, Australia
Dr Peter McDougall, Australia
Dr Mike South, Australia
ERC: 090183 March 2009
What did RCH do?
60,000
Pilot step 2: No printing
in selected wards