Patient safety culture at healthcare organizations plays an important role in guaranteeing, improving and promoting overall patient safety. Although several conceptual frameworks have been proposed in the past, so far, no standard measurement tool has been developed for Japan. The U.S. Agency for Healthcare Research and Quality developed patient safety survey tools and began to use them for collecting and analyzing data and improving safety. They include three kinds of survey tools for hospitals, nursing homes and clinics. Each survey tool consists of a self-registered type questionnaire by healthcare staff and of 3 domains and 12 categories. The categories reflect the roles of 3 different types of healthcare organizations. To research the possibility to introduce the same tools in Japan, a pilot study was undertaken using 3 acute care hospitals in Japan. The study results suggest that the survey tool (for hospitals) could be used in Japan. Further studies though are needed to demonstrate the reliability and validity of the tools for use in Japan.

A simple and fair benchmarking system or financial indicators to evaluate management efficiency and activity at hospitals have been lacking in Japan. We therefore developed 2 new financial indicators based on personnel costs：Indicator 1：ratio of marginal profit after personnel cost per personnel cost (RMP), Indicator 2：ratio of investment per personnel cost (RIP). The profitability's turning point, similar to the break-even point (BEP), is defined by the combination of the RMP and RIP.

Over a period of 5 years (2004-2008) both indicators were then applied to the 144 hospitals of the National Hospital Organization. As a result, by using these indicators management efficiency and medical activity evaluations were made possible at each hospital. 47 acute care hospitals out of 73 were in the black in 2004. The minimum RMP was 0.31. 95% of the hospitals in the black had a smaller than 0.6 RIP. Only 3 of the hospitals (25%) in the black had a higher RIP. In 2008, for the hospitals in the black the minimum RMP was 0.35. On the other hand among 71 chronic care hospitals in the black, the minimum RMP was 0.25.

This data shows that the indicators will be of use to hospital managers to evaluate management efficiency.

The development of anti-TNFα antibody and other biologic drugs changed the treatment of rheumatoid arthritis. Only facilities with specialists of rheumatoid arthritis use these newly introduced drugs, and other facilities are anxious of adverse events or side effects when prescribing biologic drugs and conventional anti-rheumatoid arthritis drugs and therefore don't use biological drugs for rheumatoid arthritis, even not Methotrexate.

Between September 2007 and November 2008, our newly developed RACRC-Path (Rheumatoid Arthritis Circulatory Regional Collaboration-Pathway) was applied to 33 patients at 14 different institutions. Collaborating hospitals were easily accessible for RA patients and several lectures about biological drugs were held for the patients.

After the first introduction phase at the National Hospital Organization Nagoya Medical Center, collaborating hospitals then continued to take care of patients with biological drugs. Patients visited the Medical Center every 6 months for blood and X-ray examination, and, in case of acute adverse events, they were able to visit the center's ER any time or even become hospitalized.

Critical pathway is useful for effective and quality care under consideration of rheumatoid arthritis characteristics.

Falls from the bed are one of the most common adverse events faced by elderly people in hospitals and nursing homes. We observed the activities of elderly people in their hospital bed at night. For four months starting in May 2006 a small infrared camera and an infrared projector were installed over the hospital beds of five patients who had high risks of falls. The camera operated daily from 9:00 PM to 8:00 AM, and the video data were recorded. Additionally an infrared motion sensor and a side-rail touch sensor were installed as well. The patients were in their seventies (three people), eighties (one person), and nineties (one person). Video data of 23 nights were captured.

Analyzing this data it was found that in total the patients rose 299 times, 128 of which were up to sitting positions, and 5 basic patterns were recognized. In 82% of the cases patients grabbed the bed's side-rail. In 65% of the cases the patients entered long sitting positions.

The results of this study suggest that a long sitting position and the touching of the bed's side-rail are reliable indicators of the desire to get out of bed.

Since around the year 2000, large hospitals started introducing electronic medical record (EMR) systems. Because of time passed and an increase of data volume, time has come to renew and upgrade the operation systems (OP). Issues related to the renewal are how to transfer the data from the old to the new system and how to change to a new customized system.

For this study, we conducted a system replacement between different venders and successfully transferred all EMR data accumulated over the past seven years (about 100 million records). With this method, the XML output (including attributes) was obtained from the old RDBMS EMR, re-converted, transferred to, and stored in the new system (XML document, DWH type data base system). This new data base system is independent from its ordering system. It stores all the generated fixed data for a long time. Traverse type access is used, so the increase of data does not deteriorate responses.

First the data transfer caused many issues. There was missing and damaged data, conversion processing, the transfer period and system downtime, verification of transfer data, the bearing of expenses, the project management, standardization for the future, and others. But finally, the system replacement and its data transfer created a new flawless information system, which facilitates standardization throughout the hospital.

Based on the 2006 Medical Service Fees revision, the Kanto Medical Center NTT EC in April 2006 changed its extramural prescriptions to generic drugs.

This study examines problems in regard to extramural prescriptions. The number of extramural prescriptions, which were changed to generic drugs during the survey period, April 2006-March 2008, was 2,228 sheets, 0.39% of the total extramural prescriptions (569,571 sheets) issued. Monthly survey results show the number increasing from 18 out of 23,569 sheets in March 2006 to 175 out of 23,743 sheets in March 2008. In terms of age range, the rate of those, who had changed to generic drugs, was higher for patients in their 50's-60's. By gender, the rate was three times higher in men than in women. By medical departments, the largest rate was found in the cardiology department：20.4% (450 sheets), followed by the endocrinology department：16.8% (372 sheets) and the neuropsychiatry department：15.7% (346 sheets). By pharmacological categories, there were 11.8% (500 sheets) for psychoneurotic drugs, 11% (468 sheets) for peptic ulcer drugs, and 11% (465 sheets) for hypotensive drugs. In addition, due to the change to generic drugs the drug price difference was 5,330 yen/sheet on average.

In those cases where the price difference between the brand name and the generic drugs is large and the prescription period is long, it is economically advantageous for patients to change to the generic drug prescription.

28.5% of all nursing home residents in Japan have difficulties in swallowing. Swallowing issues have become an important topic in the regional health care.

We provide a dysphagia home care training program for local residents and home care staff：nurses, caregivers, and care managers in local nursing homes and home care support centers. This study was conducted to evaluate the basic knowledge about dysphagia patient care and the effectiveness of our program in northern Kawasaki. 19 nurses, 17 caregivers, 8 care managers, and 26 local residents participated in the program to acquire technical knowledge on oral hygiene care, diet foods prepared for dysphasia patients, and assistance in improving swallowing for dysphasia patients. We evaluated our program using a 20-question questionnaire before and after the lectures.

Pre-lecture results showed that all the 4 groups especially except for nurses had poor knowledge about assistance in improving swallowing. The correct answer rate was not significantly different between each group but improved significantly in all groups after the lectures. Local residents improved their rate on oral hygiene significantly after the lecture. Nurses had the highest rates on diet foods prepared for dysphagia patients before the lectures. They also had the highest pre-lecture rate on assistance in improving swallowing. There were no significant differences in the rate before and after the lecture on diet foods prepared for dysphagia patients. The correct answer rate in the lecture on assistance in improving swallowing, improved significantly after the lectures in all groups. That of local residents was significantly lower. The knowledge concerning the assistance in improving swallowing was the lowest of all. Knowledge acquisition was the most effective in all the groups for assistance in improving swallowing. Dysphasia patient care was the most basic knowledge of home care staff in comparison to nurses and other home care staff.

Our study suggests that this training program is useful in improving the technical knowledge of dysphasia patient care.

Although a critical pathway is useful for a standardization of medical care, improvement of quality, and establishment of a management base, variance analysis is indispensable to guarantee proper content. Although the Kagawa Rosai Hospital had introduced a variance analysis system using an electronic critical pathway, the variance registration was such a serious task, and sufficient registration could not be obtained.

Therefore a new system, which performs the registration of the outcome evaluation at the time of discharge of the hospital, was introduced. The outcome was classified into two types：a “common outcome” and a “critical pathway specific outcome”. The “common outcome” was compiled from four items：the “clinical outcome”, the “QOL outcome”, the “time outcome”, and the “economic outcome” which is common in all critical pathways. The “critical pathway specific outcome” was complied from an item reflecting the trait of each critical pathway.The outcome evaluation registration at the time of hospital discharge became possible, and data collection for the critical pathway analysis became easily possible.

Although this system just started operation, the hospital wants to analyze the components of the medical quality (structure, process, and outcome) using various evaluation indexes accumulated from now on, and plans to continuously reform its critical pathway in the future.

Serious patients' fall incidents have been increasing over the past 3 years in the ICU as a result of the height of hospital bed-rails. After testing the safety of a common ICU bed, it was found that the height of the side-rail was insufficient for the prevention of patients' falls from the bed. We therefore developed two new types of detachable fence bed guards as a countermeasure：an extra accessory rail type and an acryl board type, which were then assessed by nurses in the ICU setting. Although the impression of restraint was stronger with the accessory rail type, it allowed easy access to infusion devices and useful tube management. The acryl board type gave a much lesser restraint impression and because of its transparent material a good view all the way to the bed sheets, however, because of its weight, installation was inconvenient. In addition due to their height, both types did not enable patients to be change without detaching the guard from the bed. In conclusion, both types have considerably improved the prevention of bed falls in the ICU, however they are still inconvenient for nurses to handle and uncomfortable for the patient.

A new device is still needed to improve the prevention of bed falls including convenience for the handler and the patient.

When drawing up a critical pathway, it is difficult to select outcomes appropriately. This study analyzes 1,137 outcomes of 450 critical pathways used at the Kumamoto Medical Center. The outcomes were classified into five groups：1) Patient findings, 2) Treatment, 3) Life activity, 4) Education, and 5) Others. In addition a list of examples of outcomes from each group was made up. This kind of terminology is useful when designing a critical pathway.