Establishing and using a critical path is useful for the improvement of medical quality. Furthermore, it is important to repeatedly revise it while in use. A critical path can be improved based on four approaches：1) comparison with critical paths used at other institutes, 2) investigation of evidence based medicine, 3) analysis of the DPC data and 4) variances-analysis of the critical path. In this study, we present our experience in the revision of a critical path at the National Hospital Organization Kyushu Medical Center.

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Since the number of hospitals reimbursed by DPC (diagnosis procedure combination) has been expanded, huge amounts of data from hospitals have been compiled and made public. As a result, transparency and standardization of medical care have been expanded and various new information analyses make it possible to compare the different medical institutions.
One of the specific points of DPC compared to medical care based on FFS (fee for service) is that the purpose of a patient's hospitalization is clearly shown. A critical path operates for a specific purpose of hospitalization and some revision is required in order to enhance standardization and effectiveness.
This study shows that the DPC benchmark analysis is a useful tool for critical path revision.

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The easiest way to understand “variance” is to interpret it as “a condition, when an outcome is not achieved" . In order to define this term, “outcome” must be also defined, but there is no national-standard definition for it. Hence, it must be defined by each hospital. The method to collect variance is determined according to this definition. Out of all the collected variances those, which need to be studied by multiple occupation types, were selected. Once these were discussed on the basis of multiple occupation types, suggestions were made to improve particular matters. The PDCA cycle will function by revising the critical pathway and re-using it to conduct a variance analysis.

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After the preparation of cost accounting data classified by patients in the first study, this study researches cost accounting classified by medical department. Eight different medical departments were analyzed and additionally patients including seven different types of critical paths, cost accounting classified by critical path, a Diagnosis Procedure Combination (DPC) analysis and the benchmark at several institutions were examined.
The ranking changed noticeable according to examined items such as number of hospital days, income, profit (income-cost), profit ratio (profits/income) and profit per one bed per day. In regard to expensive direct material costs profit rates were low at two medical departments.
Analyzing the cost accounting classified by the critical paths, no problem was identified for the paths of un-ruptured cerebral aneurysm clipping and carotid endarterectomy. An amendment of the length of hospital stay corresponding to the DPC payment system was required for the paths of pacemaker implantation, abdominal total hysterectomy, distal gastrectomy and mastectomy (drain insertion). On the other hand, for femoral neck fracture (Bipolar hip prosthesis) and pacemaker implantation, the profit ratio was as low as 21.6% and 24.1% respectively, because of the expensive direct material cost. Additionally standardization of the heart and blood vessel reference as well as orthopedic surgery material and measurements for purchasing quality products for lower prices were introduced.

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Recently, the numbers of patients with prostate cancer are increasing as well as the proportion of the examination time at outpatient clinics. This is leading to an extension of not only clinic hours but also of patients' waiting time. To improve this situation and reduce the burden on patients, the Toyota Memorial Hospital attempted to introduce a liaison critical pathway for stable patients with prostate cancer in hormonal therapy. Indications of the critical pathway are：1) the patient is in hormonal therapy, 2) the patient's PSA level is below 0.2ng/ml, 3) the patient is well aware of the side effects of the hormonal therapy and 4) the patient is meeting the above criteria and is in stable condition since over 3 months. Home doctors were then requested to treat patients continually after the hospital's referral, refer them back to the hospital if their PSA level increases above 0.5ng/ml and patients were required to visit the hospital once a year in their birthday month regardless of their PSA level. 28 patients participated in this pathway over the period from February 2008 to January 2009. Results were verified in a questionnaire, which had been given to the home doctors and showed that the pathway is manageable and useful.

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Prevention of side effects is an important aspect of cancer chemotherapy. In order to provide appropriate drug information and to manage side effects in patients undergoing cancer chemotherapy, the Kagoshima Kouseiren Hospital in July 2008 introduced an original medication log, which documents the chemotherapeutic protocol.
This study evaluates the clinical usefulness of this log by comparing the number of event occurrences over the period January to June 2008, before the introduction of the log, to the period of July to December 2008, after the introduction of the log.
With the introduction of the logs, verification of the remedy as well as side effect monitoring became possible. Over a period of 6 months the number of incident and accident reports concerning the cancer chemotherapy decreased from 4 to 2 and the cases of use of antiemetic (5-HT_３ receptor antagonists) increased by about 2.1 times. Furthermore the number of patients for whom it became difficult to continue the treatment because of side effects from paclitaxel and carboplatin decreased from 5 (3 cases；inappetence and nausea) to 1 (neutropenia).
The results suggest that the log is useful for patients to understand the protocol of their cancer chemotherapy as well as to manage side effects.

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Hitachi Mito General Hospital (215 beds) has developed a new system and injection order sheet allowing the pharmacists to prepare all anticancer drugs although there was no computer order entry system. With the new system, modifications to a prescription can now be made daily as needed. Furthermore, all modifications are entered into the hospital's intranet system and through its search function, not only the physician who registered a regimen, but any medical workers can now easily perform the confirmation of a regimen. In addition, because patient education and guidance by pharmacists and nurses start from the beginning of the ambulatory cancer chemotherapy, all patient's treatment and care are now recorded on just 1 sheet per treatment day on the patients' record papers to facilitate sharing of patient's information.

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When considering cooperation between a base hospital and its local community hospitals to provide palliative care for cancer patients, there is a need to investigate problems that might arise from time to time. Through group meetings with staff from several nearby small and medium-sized cooperating hospitals possible problems were investigated and solutions were proposed by the KJ technique.
The problems of patients and their families included anxiety about their illness, hopes for successful treatment, incorrect perceptions about their medical condition, a feeling of abandonment by the base hospital with regard to cancer care (base hospital), and anxiety in regard to the cooperating medical institutions (cooperating hospitals).
The problems of the cooperating hospitals included gaps in medical knowledge between the base hospital and the other hospitals, lack of information from the base hospital, and the timing of transfers from the base hospital.Lack of sufficient attention towards the cooperating hospitals, insufficient understanding of the necessary information for the cooperating hospitals, and providing insufficient explanation to patients and their families at the time of the hospital transfer were pointed out as problems of the base hospital.
The proposed solutions included providing tours of the cooperating hospitals, holding a conference before the discharge of the patient and setting up a system that would allow patients to transfer back to the base hospital as needed. In addition to the cooperation between the medical institutions, understanding the viewpoint of the patients and their family members was considered important. Furthermore, the discussion of problems through group meetings was considered an important process for a smooth cooperation in the community.

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This study aims to explore how the electronic health record (EHR) can improve communication between visiting nurses and doctors in the elderly homecare setting. An EHR system implemented in the Yamagata prefecture's Tsuruoka region can be characterized as an asynchronous rich communication media. To elucidate the effect of the use of EHR on communication between doctors and nurses, the nursing records of 17 homecare patients with EHR and 17 patients without EHR were examined and compared over a period of 14 months from April, 2005 to June, 2006. These nursing records included both formal and informal reports such as telephone, fax, email and EHR communication. Semi-structured interviews were also carried out with 9 visiting nurses in order to reveal how they perceived the effects of the EHR. The number of information details transferred from nurses to the doctor over this study period was 453 for patients with EHR and 301 for patients without EHR. This difference was explained by the use of electronic communication. Furthermore, the interviews with nurses indicated that the use of the EHR reduced their psychological barrier of communication with doctors and ensured better learning, mutual understanding and trust between nurses and patients. Communication between nurses and doctors over the homecare patients with EHR exceeded in terms of quantity and timing, which leads to better treatment and care.

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An in-hospital chart audit on 1000 inpatient medical records (186 prepared by residents and 814 by supervising physicians, who have been practicing for over 3 years） was conducted by health information managers at the National Hospital Organization Himeji Medical Center. The physicians' records were valuated based on 20 items. Audit results show that the physicians' records scored on average 14.19±3.26 (out of 20), while charts prepared by residents scored significantly better. The audit also demonstrated that 5.1% of the nurses' records were prepared incorrect.
Since 2005, the institution has been holding hands-on learning experience seminars called：'simulation of medical chart disclosure', in order to educate its residents. A supervising physician, whose records needed improvement, was also asked to participate. Attending such seminars has improved medical record-preparation skills significantly. In addition, hands-on learning experience seminars including group discussions were also conducted, using as teaching materials problem records prepared by nurses and others of an incident's case. Based on a survey of participants, results show that these seminars were useful in acknowledging the importance of maintaining appropriate medical records.
In conclusion, introducing hands-on learning experience seminars after chart audits is a valued way to improve chart preparation skills.

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In order to prevent adverse events in regard to medication, pharmacists at pharmacies and hospitals must be actively involved in the risk management of drugs.
As a first step for a risk management in regard to drugs at the Nanto General Hospital's pharmacy, an analysis of medical incidents was conducted and measures to prevent dispensing errors were taken. As a result, the number of medical incidents decreased significantly, especially, calculating errors. In addition, visual efforts such as medicine cabinets' arrangements and drug indications to prevent dispensing errors were newly executed. These steps effectively increased pharmacists' attention and consciousness to prevent medical incidents.
Furthermore, as another step of risk management in order to decrease improper preservation or use of drugs at the hospital, the volume, cost and factors of drug damages and injection-mixing errors were investigated. Pharmacists also suggested other measures to improve the work environment at other stations and to reform the overall consciousness at the hospital like wrong impressions and thorough confirmations of instructions by physicians. As a result, a decrease of drug damage and injection-mixing errors was observed.
Because of the improvement of the work environment and the reformation of the consciousness of each medical worker, risk management in regard to the drug supply at the Nanto General Hospital as a whole can be considered effective.

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About seventy artificial respirators are continuously in use at Nishibeppu Hospital for patients with neuro-muscular diseases. To operate these respirators nurses are required special technical knowledge. To improve the nurses' technical skills for the use of the artificial respirators, mandatory courses of “Breath Treatment Nurse Certificate” were introduced in 2004. A team of doctors and breath treatment specialists of all three associations hold these courses.
After the first 3 years Nishibeppu National Hospital can report the following results：During the first year, the position of acknowledged specialists (Nintei-shi) was established at the hospital.During the second year, the course content, methods and situation of participation were discussed.
In the third year the course started and a problem evaluation was conducted based on a survey of participating nurses. In addition future tasks concerning the position and function of the acknowledged specialists (Nintei-shi) were clarified.

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