The purpose of home care is for patients to regain their independence so as to be able to take care of themselves as much as possible and to be able to spend meaningful time for the rest of their lives. In order to achieve this goal, we demonstrated the effectiveness of a newly developed critical path for home care patients. It was essential to minimize the discrepancy of the level of the standard care among the caring staffs. The critical path developed in this case is based on the degree of the care regarding the different health conditions of patients, their everyday life and functional training.
As a result of this study we succeeded in an expansion of daily living (ADL) activities, an improvement of the degree of care needed and a standardization of the quality of home care services.

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In correspondence with the Diagnosis Procedure Combination (DPC) System of Japan critical paths for malignant lymphoma (ABVD regimen, Biweekly CHOP regimen, R-CHOP regimen, R-FND regimen) and acute myeloid leukemia (AML) (remission induction and consolidation regimen of patients either up to or over 60 years old) were drawn up and the medical profit was thereby estimated. Contrary to the Fee For Service system, with the DPC system the medical profit regarding patients with malignant lymphoma decreased because hospital stay was shortened. On the other hand for patients with AML the medical profit increased with the DPC system.
We therefore concluded that critical paths, which corresponded with the DPC system, are meaningful for the management of medical profits when treating hematological malignancies.

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Medical treatment fees are blanket payments at for DPC and cost management is required to perform within the limits of remuneration. Although with the introduction of the critical path at the Kagawa Rosai Hospital standardization and an increase in efficiency of medical treatment was attained, in order to analyze cost information further, a cost accounting system classified by patients was developed. Information from the medical-affairs accounting system, the DPC software and data from the electronic critical path software as well as from personnel affairs and salaries was included in the new cost accounting and analyzed. A cost accounting performance on 12 patients of un-ruptured cerebral aneurysm neck clipping showed earnings of 22,194,125 Yen, prime cost of 5,538,825 Yen, a profit of 16,655,300 Yen, a return rate of 75%. The profit per patient was 1,387,941 Yen. It was also learned that most profits were profits from operations. Average hospital days are within the limits of the duration of hospitalization II, the DPC income exceeds the overall earnings and the results show that the critical path of un-ruptured cerebral aneurysm clipping responds to DPC.
Our study shows that uniting cost accounting classified by patients with a critical path can visualize clinical best practice and economical best practice and consequently contributes to the improvement in quality of medical care.

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Based on a questionnaire survey (collection rate: 60%) regarding the perioperative management of radical prostatectomy (RP) in 1,213 educational institutions of the Japanese Urological Association, this study investigates the relationship between critical pathway usage, several perioperative management settings and institutional backgrounds.
A critical pathway was frequently used in the Chugoku-Shikoku districts and in hospitals having 401 beds or more, 3 or more urologists and/or 31 or more beds for urology and also used more frequently as the number of annual RP increases. But it was infrequently used in hospitals having 10 or less beds for urology, not having a computerized medical system or not having an ICU and/or Department of Anesthesia.
Logistic regression analysis demonstrated six significant backgrounds affecting critical pathway usage:district (Tokai-Hokuriku, Chugoku-Shikoku), university hospital, 7 or more urologists, annual RP rate of 11 or more patients, computerized medical system and ICU. Standard deviations were very large, although critical pathway usage provided significant early initiation of walking and oral food intake significantly shortened the period of intravenous and parenteral prophylactic antibiotic administration, provided significant early removal of drain and urethral catheter and significantly shortened hospitalization. District, the number of urologists and annual number of RP affected the majority of the ten perioperative settings on multiple regression analysis. Perioperative management of RP can currently not be standardized in Japan, because each hospital operates with individual critical pathways.

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The critical path for total knee arthroplasty at the National Hospital Organization Kumamoto Medical Center states that patients, who have experienced no postoperative infection, are able to walk using a cane and underwent surgery before three or more weeks, shall be discharged. However, a large proportion of these patients actually move to another hospital for further rehabilitation before returning home. Therefore, it seemed necessary to develop additional criteria to determine the timing of discharge according to the conditions and performance of the individual patient. For this study we assessed 78 patients (8 males and 70 females), who underwent total knee arthroplasty at the Department of Orthopedic Surgery, in regard to their mobility and the range of joint motion at the time of discharge. The patients were divided into two groups: patients who returned home directly and those who moved to another hospital and their assessment results compared. The results demonstrate that the mobility of the patient was a factor influencing their decision to move to another hospital, while the range of joint motion was not. Whether or not a patient has acquired the ability to walk freely using a cane is an important factor affecting the transfer after discharge. Therefore additional criteria for the critical path should include the beginning of training to walk with one crutch.

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This research studies patients' evaluation processes when choosing a healthcare facility. For the study we classified the factors that influence patients' choices for a healthcare facility into three categories: “technical factors", “people factors" and “amenity factors". We analyzed the differences in the evaluation of each of these factors from the viewpoint of patients who had experienced healthcare service in said healthcare facilities (existing patients;experienced) and those patients without experience (new patients;non-experienced).
Our study shows significant differences between experienced and non-experienced patients in evaluating “technical factors", “people factors" and some of the “amenity factors".
One factor, “waiting time"(included in “amenity factors" ), was not described as significant in the decision process by both types of patients. On the other hand, for non-experienced patients “technical factors" and “amenity factors" had a strong influence on their choice of a healthcare facility, while for experienced patients the “human factor" had a strong influence on their decision.
Healthcare facilities which hope to increase their service usage by developing a new marketing strategy should be aware of the different values that existing and new patients focus upon.
Follow-up studies are recommended to further understand the process, how patients evaluate and choose health care facilities.

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In order to determine the current status of patient harassment of medical professionals in Japan, we conducted a survey of 16 medical facilities from throughout the country. We defined patient harassment as constituting “an unjust demand on, or abusive language or violence (including sexual harassment) toward medical staff by a patient or a patient's family." The participating facilities reported only 116 cases, which were much fewer than expected. It was assumed that the cause was either underreporting due to a lack of understanding of what constitutes patient harassment or was a result of a problem with the data collection procedure. Patient harassment was reported by medical staff in all positions and at all times of the day, with male patients in their 40's as the assailant in many cases.
In less than half of the cases it was found that the patient harassment concerned an entirely false charge against the staff member. More than half of the cases were considered to have resulted from a problem peculiar to the patient's medical treatment, which concerned the illness itself or a mistake in care that was considered not to be serious from a medical viewpoint.
Although many victims were female nurses, staff members from across a wide range of medical fields were subject to harassment. Staff reported not only a feeling of fear and displeasure, but in many cases also reported becoming pessimistic. Thus, immediate measures against patient harassment of medical staff are required.

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This study analyzed the implementation of “Community Health Care Room", an virtual nursing advising service at the Tokushima University Hospital, which was introduced in April 2004. Between October 2005 and March 2008 we examined website visits and usage such as search key words, access counts, users' areas, browsed time zones and frequently browsed questions, using an access log analysis software. Over this period convenience was improved through an accumulating database and information with more outer links was added. By the end of December of 2007 the consultation details were finalized and a total of 1,221 questions and answers for categories such as intractable disease, psychiatric disease, cerebrovascular disease, pediatric disease, dental disease, cancer and palliative care were entered into the system.
Results revealed that the website was accessed from all prefectures in Japan, and half of them were from Tokushima prefecture. The morning hour at 11 AM is the most frequent browsed time zone;the 4 AM nighttime is the least accessed time. Questions in the category of disease and health problems were the most frequent browsed questions, followed by regarding medical and welfare institution and financial problems. While questions were constantly added, access increased year by year. Currently the hit count has exceeded 100,000 accesses per year. Since 2008 our website maintains its top position in the internet with the search word “Community Health Care Room".
Our survey reveals that the website has accomplished its original purpose and successfully maintains its “anywhere, anytime, by anyone" 24-hour information service about health, medical and welfare.

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This study shows an improvement of the critical pathway operation at the Shonai Amarume Hospital by actively involving the health information manager in the critical pathway committee, which originally included only physicians, nurses and co-medical staff. During the first two years of his participation, the health information manager was involved only partially, however during the latter two years, the health information manager got involved extensively in the maintenance of the management regulations and variances' regulations.
As a result, the management system of the critical pathway was unified including all departments at the hospital. A LAN system nowadays enables a printout of the management rules and the critical pathway forms from anywhere in the hospital. Patients' critical pathway data was integrated into the patients' clinical database. Through this, instead of the original 6, 51 patients' data could be accumulated. Additionally, the variances' regulations were newly established and clinically applied, resulting in a significant increase of the ratio of variances' numbers for each critical pathway (p<0.05, χ2 test). By analyzing the variances, several changes were added to the critical pathway, which resulted in a significant decrease in the negative consequences of variances (p<0.05, χ2 test).

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Liaison critical pathways (pathways) can be considered a product of incorporating critical path methods for medical collaboration. The Central Kochi medical care area is a regional core city-type area with a population of 570,000. With the objective of improving and making more efficient use of collaborative care for cerebral stroke we developed a liaison critical pathway for application in an entire secondary medical care area. Professionals from various fields at multiple facilities participated in the development and government and medical associations were involved from the start. In July 2008 pathways were introduced with the participation of 5 acute phase hospitals and 27 sub-acute phase hospitals.
We focused on collaborative care for cerebral stroke and developed four types of critical pathways based on collaboration patterns. Critical pathways comprised in-hospital pathways and concurrently executed pathways, and did not delve into the contents of medical care. Specifically, issues related to collaboration were managed using collaboration critical pathways, while the contents of medical care were managed using in-hospital pathways. Each of the four critical pathways consists of an overview and an information sharing form. The information sharing form is divided into four parts: an acute phase, recovery phase, maintenance phase and the primary care physician, and it is similar in format to daily critical pathways of in-hospital pathways. This same form was established in all four critical pathways to enable the use even after future changes in collaboration patterns. The pathways are to be implemented for a one-year period from the onset of the acute phase and scheduled to be revised every two years to reflect revisions to medical service fees. Problems regarding the initial stage of implementation were examined during the development.
Unification of evaluation criteria and standardization of care in the community can often be achieved during pathway development and the initial stage of implementation. However so far, community-wide support for cerebral stroke, that uses collaboration pathways as tools, is limited to inter-hospital collaboration. Collaboration with primary care physicians and homecare services is still an issue.

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The Department of Urology of the Chiba Cancer Center, in association with urologists of regional private clinics, revised the regional cooperation critical pathway (hereafter,“path") for urological cancer with the aim of promoting regional cooperation and improving the efficiency of the services provided to outpatients. To make follow-up observations easier for the concerned doctors, 3 paths were developed involving the use of the prostate-specific antigen (PSA):the post-prostate biopsy PSA follow-up path, the post-prostatectomy follow-up path and the endocrine therapy path. Initially only these 3 paths were used but currently the cancer center employs a total of 6 paths:4 post-prostate cancer-related paths and 2 bladder cancer-related paths. At the end of September 2008, a total 224 patients had been introduced to the cooperating medical institutions and so far encountered 2 examples of variance. When a questionnaire was presented to the urologists at the cooperating medical institutions and at the Chiba Cancer Center regarding the paths, the opinions obtained were generally favorable. Since not even a year though has passed since these paths were introduced, the data are yet insufficient to establish a connection between them and the services provided. However, continued utilization of the paths and, more importantly, an increase in the number of participating facilities can pave the way for the development of new paths and medical treatment modalities.

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In 2001 the Saiseikai Yokohama-shi Nanbu Hospital introduced a critical pathway in order to standardize medical services and promote team medical care. This survey examines the effects of this critical pathway's introduction by investigating the nurses' consciousness towards it through a questionnaire survey.
The survey results show that overall medical diagnosis and treatment as well as nursing care at each department were standardized and services' effectiveness has been improving. Some areas though still show insufficient results in regard to medical treatment and patient services and there remains the necessity to review the causes.Moreover, nurses seemed to be reluctant to changes and additional orders by physicians, but tended to continue their routine work. Additionally the survey results show that risk management and team medical care had not been approved sufficiently by the introduction of this critical pathway and further studies are necessary to improve it in this direction.

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This study examines the diabetes management plans of the Toyota region (Toyota city, Aichi Prefecture) and recommends an entire regional medical cooperation plan for continuous care from primary to tertiary preventions. The Toyota Memorial Hospital has a well-established outpatient referral system and a short-term educational hospitalization program and the hospital plays an important role in the initial diabetic education and reviews of diabetes. Various meetings to promote closer regional cooperation are already established and emphasize open discussions among small groups of physicians. The Toyota region medical staff mainly self-manages the society to extend their skills. They also discuss the database for their regional cooperation.
In order to achieve regional cooperation in the whole Toyota region, a Toyota City Coordinating Council for Diabetes Management has been set up in 2005 through participation of not only hospitals and clinics but also local administrative bodies, industrial physicians and health insurance societies. The Council has accomplished the printing of a diabetic educational pamphlet. Moreover, it has analyzed data regarding fundamental health inspections and conducted a survey of diabetic patients. In addition the Council has also established a nutritional support system for lifestyle-related diseases such as diabetes and dyslipidemia in clinics without dietitian. A short-term educational hospitalization program in cooperation with industrial physicians led to the reduction of HbA1c among employees in this area.
In order to achieve regional diabetic disease management without organizational barriers in the Toyota region, both human resources and information are thought to be public property. In diabetes management, simple cooperative links between hospitals and clinics are insufficient and a more comprehensive management is needed.

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In response to complaints and claims by patients, the Fukui General Hospital in April 2002 introduced a unique flow chart, which consists of 3 phases, primary through tertiary. The primary and tertiary phases corresponded to those conventionally practiced where a general risk manager (GRM) is not involved. In the secondary phase a GRM maintains a neutral position. In the most sensitive portion of this phase, its final segment, a meeting was introduced to allow for discussion between the parties representing the patient and the medical personnel. Also in attendance at the same meeting is an impartial GRM.
Results of the introduction of this new system show:1) In spite of the initial discrepancies in understanding by the parties involved, they eventually came to an amicable view of the situation;2) Both parties accepted the intervention by the GRM, who was regarded as a member who was impartial in regard to both parties;3) Arranging for this meeting as well as the intervention by the GRM not only avoided unnecessary legal disputes but also resulted in a solution acceptable for both sides, which was more reasonable than if legal means had been pursued;4) The average number of days required for the secondary phase was 33 days (range from 2 to 195 days).
As a result, it is believed that establishing a trusting relationship between the GRM, patients and medical personnel is of primary importance when attempting to reach an amicable settlement in these kinds of cases.

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This study investigates the influence of a combined authentication system and computerized physician order entry (CPOE) system in regard to quality and quantity of near-miss reports in administering medications. The authentication system scanned bar codes of pre-packaged drugs, patients' identification bands and medical stuff name card prior to the administration of the drugs. The intake of oral medicines, on the other hand, was confirmed by watching the administration on a computer screen.
As a result, after the introduction of the authentication system the ratio of the near-miss reports for medication injections decreased, whereas the ratio for oral medication administration increased. The ratio of incident to accident reports didn't change for the oral administration, but increased for the injecting administration. For administrating medication the ratio was reduced the most in the process of information transmission from prescribing doctors to the pharmacy, because by using the CPOE system compared to human action human error was minimized.
The authentication system, especially combined with the CPOE system, has strengthened detection of the occurrence of errors in medication administering. It contributes to the improvement of the safety in medical treatment.

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In 2006, two cases of fatal medical accidents in which endotracheal tubes were dislodged, while nurses were repositioning the patients, occurred at National Hospital Organization (NHO) Kyushu area hospitals. In both cases, one of the major factors causing the accident was traction on the endotracheal tubes by ventilator circuits during the repositioning procedures. As a result, at two educational meetings at NHO Kyushu area hospitals it was recommended that the ventilator circuits should be temporarily disconnected before repositioning to avoid traction. Before these meetings, only five of 25 hospitals had defined manual procedures that instructed nurses to disconnect the circuits during repositioning. However, following these meetings, by 2008 21 of 24 hospitals re-wrote their manuals to instruct nurses to disconnect the circuits. A cross-sectional survey in January 2008 demonstrated that 73.9% of 3,549 patients in NHO Kyushu area hospitals were repositioned after disconnecting the circuits. In only one case, repositioning was performed by a team of a doctor and a nurse, while the remaining cases were repositioned by nursing staff only. Twenty-one hospitals, where the manual indicated that tubes were to be disconnected during repositioning, indicated that there were no problems during the performance of these procedures. These results suggest that the procedures to temporarily disconnect the circuits during repositioning can be safely performed by nursing staff alone.

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The PRE-AVOID (be PREpared to AVOID adverse drug reactions) program at Hino Hospital is part of the pharmaceutical care by hospital pharmacists including instructions on the use of drugs. However, regardless of its efficiency as a part of risk management, the program is thought to not yet be well known among doctors and nurses at the hospital.
This study examines and assess the knowledge of “PRE-AVOID"by doctors and nurses at the Hino hospital. 20 doctors and 51 nurses took part by filing survey sheets on awareness, importance and the necessity of feedback about “PRE-AVOID". Although 88.9 % of doctors and 61.4 % of nurses did not know the program, most considered it important and hoped for feedback on it. Thus, so far the program is used among the hospital's pharmacists, but this study shows a necessity to further spread information about it among the other hospital staff.

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