Purpose: In radiation oncology, there is a significant amount of technical documentation that must be recorded and stringent quality analysis data that need to be logged, requiring considerable use of paper and substantial investment of time. Our goal was to reduce—and eventually eliminate—paper documentation of this information and to go paperless in the department, using LEAN Six Sigma methodology to improve efficiency, reduce errors, and decrease waste.
Methods: From February 2013 to April 2013, the LEAN Six Sigma process was applied to make the radiation oncology department as paperless as possible. To obtain baseline data, 15 random charts were pulled, and the number of sheets in each was counted. The current process map was assessed, and the flow of the physical chart was diagrammed, along with identification of points where sheets of paper were added. Forms were evaluated to determine necessity, redundancy, or ability to be converted to an electronic format. To allow for electronic documentation, the ARIA Computer Record and Verify system was used since CPRS is not an appropriate nor feasible place to record this technical information. ARIA capabilities such as electronic prescription entry were set up to eliminate paper prescription card usage. The automatic recording capabilities of ARIA were explored to determine the information already captured in the computer system. Paper forms were recreated digitally and made into Dynamic Documents in ARIA, which were then filed under each patient. After implementation of these changes, 10 random charts were pulled and the number of sheets counted to record improvement.
Results: The average number of sheets of paper per chart was 46 (range 18 to 110) before implementing the changes. All forms except a select few (history and physical examinations forms, American Urilogical Association score sheets, and Sexual Health Inventory for Men score sheets; all 3 of which are filled out by the patient at time of consultation) were found to be redundant and eliminated or were converted to an electronic format. ARIA was used to record delivery of daily doses automatically from the treatment machines, eliminating the manual recording of daily treatment. The prescription card was eliminated with use of the ARIA electronic prescription entry. Items such as the Time Out Sheet, RTT Patient Set-up document, RadCalc/Mapcheck forms, and the RT Completion Record Checklist were all converted to Dynamic Documents in ARIA. After these changes were made, the average number of sheets of paper per chart was 3 (range 1 to 6).
Conclusions: By applying LEAN Six Sigma thinking, we were able to decrease paper usage by 93%. Documentation is clearer, since most data is electronically entered, and potential for error is likely reduced due to the elimination of problems with illegible handwriting. Flow through the department has improved, since no physical charts need to be transferred, and staff members have access to the charts simultaneously. Time is also saved because of this and because a chart writeup is no longer necessary, since there is automatic documentation.