Clinical indicator in Kyoto City Hospital

Abstract

Along with the preparation for receiving accreditation version 6 of the Japan Council for Quality Health Care (JCQHC), data of 11 clinical indicators (CIs) including 5 essential CIs required for the accreditation, and 6 CIs already used by committees or divisions in our hospital, were collected and analyzed. In order to improve quality of medical care, we investigated new CIs using data reported from other hospitals, the reform plan for medical quality of our hospital and data already collected by committees or divisions in our hospital. Finally 35 CIs in 8 dimensions were adopted and the data were analyzed through hospital information system and health information management office. To promote understanding of definitions and significance of these CIs among hospital staff, in-hospital seminars such as “Safety Management Seminar for Higher Quality of Medical Care” and “Kyoto City Hospital Annual Meeting” were held.