We ascertained the differences and disparities in critical pathways for pulmonary lobectomy among National Hospital Organization (NHO) facilities. In light of the results and clinical evidences, we devised a “best practice” model of the critical pathway for pulmonary lobectomy.

All NHO facilities nationwide were surveyed and their critical pathways for pulmonary lobectomy were ascertained. Items used to compare the listed content of the critical pathway were overall specifications in the form of eligibility criteria, outcomes of patient, discharge criteria, and duration of hospitalization and perioperative management in the form of preoperative breathing exercises, preoperative hair removal, measures to prevent pulmonary embolism, prophylactic antibiotic administration, epidural anesthesia, ECG monitoring, O2 supplementation, urethral catheterization, chest tube management, ambulation, meals, wound care, bathing/shower, postoperative inhalation therapy, postoperative rehabilitation, and lab test scheduling.

Critical pathways at 36 facilities were available for study. In terms of overall specifications, many facilities did not have clearly defined eligibility criteria or discharge criteria. In terms of perioperative management, some forms of care/management tended to be consistent but differences and disparities among facilities were present. Some facilities also provided medications and treatments that deviated from guideline recommendations. Based on survey results, the most recent guidelines, and Diagnosis Procedure Combination payroll system, a standard and recommendable critical pathway was devised.

Among NHO facilities, the differences and disparities in critical pathways for pulmonary lobectomy were present. Whether or not the “best practice” pathway devised can serve as a true best model must be determined on the basis of aspects like the incidence of variance and patient satisfaction.

This study was conducted to assess diagnostic skills between urology specialists and non-specialist when liaison critical pathway was used in transfer of both suspected and diagnosed prostate cancer patients. The levels of patient's confidence towards the two separate groups of liaison doctors were also assessed.

The pathway was used for 147 patients between November 2007 to February 2009, of which 77 had been introduced to the urologists and 70 to non-urologists. By February2010, 10(13.0%) patients returned to our hospital from urological cooperating institution and 14(20.0%) from non-urological. Of the 10 patients revisited from urological institute, 8(10.4%) were for reason of increased prostate specific antigen (PSA) level. Among them, 6 patients were diagnosed as biochemical recurrence and 1 as prostate cancer. As for patients revisiting from non-urological institutes, 12 out of 14 patients (17.1%) had increased PSA levels, 5 were diagnosed with biochemical recurrence and 2 with prostate cancer. Doctor confidence assessment was conducted toward 64 patients working with urologists and 54 with non-urologists for whom it was possible to perform follow-up observation, and no significant difference in the diagnostic capability of the prostate cancer between both home doctors was found.

Moreover, according to the questionnaire carried out simultaneously involving 60 patients, no substantial psychological difference were observed in patients that agreed to participate in the medical cooperation, regardless of the specializations of the home doctors. As a result, we believe that, by clearly defining the outcome, it is possible to establish efficient medical cooperation using regional liaison critical pathway, regardless of the partner doctor being a non-specialist.

The recent medical reform has complicated medical documentation and increased administrative work load of physicians. This has caused increased level of exhaustion and consequently impairs the quality of medical care. In April 2008, we established a new unit consisting of 8 medial clerks to reduce physicians' administrative work load. This study was conducted to identify the changes in workload and measure the physicians' satisfaction. Major monthly outcomes were preparation of 1068 medical certificates and completion of 1711 inputs of a basic attribute of discharge summaries. Mean monthly overtime hours were reduced by 8.3 hours. Other requests were medical conference assistance, output of clinical indicators and intra-hospital seminar assistance for physicians or patients. The monthly requests were 10, 5.5 and 2.5 cases, respectively. On effectiveness of the new unit, 82% were satisfied in preparing medical certificates and 64% were satisfied in discharge summaries. Satisfaction in seminar assistance (91%) and clinical indicator output (84%) was also indicated. The newly established medical clerk unit is effective not only in reducing physician's administrative load but also in satisfying various demands which can contribute to their self-education and team approach, leading to the improvement of healthcare quality. Also, the opportunity to give a variety of medical support can encourage clerks to expand their ability and increase their satisfaction.

To effectively implement medical safety measures, it is necessary to assess the working environment and illuminate problems to create suitable countermeasures. We evaluated the knowledge and activity of the medical safety of all employee using the human error management self check sheet (HEM sheet) which can evaluate the penetration of medical safety activity and the problem of the organization. The HEM sheet consists of 7 questionnaires；the basic concept, workplace atmosphere, check system, accident investigation, recurrence prevention, prevention organization, and strategy relating to the knowledge and activity of the medical safety. The number of valid response was 406 out of 521 persons (response rate 77.9%) in 2006 and was 496 out of 579 persons (response rate 85.7%) in 2007. The degree of achievement of seven analysis indices from 2006 to 2007 was improved in all the indices. The penetration of the interest and knowledge about the medical safety of clerical staffs was less than the other occupational staffs. On the other hand, it seemed that the effective medical safety activity in 2007 resulted in the decreasing of staffs with low self-awareness of medical safety in each index. However, it was suggested that the reeducation was needed to the clerical staffs with low self-awareness of medical safety than other occupational staffs. In this study using a HEM sheet, the issue, such as the recognition and understanding of the medical safety activity of the organization and status of preparation of the framework of medical safety measures, became clear.

Bed-fall prevention in elderly people at night is one of the major issues of patient safety in hospital.

In the first paper, we analyzed the patients' motions leading to a fall from beds during sleep, and categorized characteristic movement pattern of patients. In this paper, we report a prototype system to prevent accidents based on our findings and its examinational result in a hospital. We call the system “Mimamori-Bed” (the watch and support bed). The system has several sensors and detects the patient motions：when sitting up or getting out of bed. In addition, this system automatically actuates a nurse call system and gives patients an audio warning when it detects patient motions. One-patient-trial was conducted for five consecutive days during which 41 nurse calls were triggered by our system. Interview to nurses participating in the trial were that the reaction time and detection accuracy were sufficient in performing their jobs.

We compared the medical fees of the National Health Insurance of conventional open surgery with that of endovascular aortic repair in patients with abdominal aortic aneurysm. Endovascular aortic repair was undergone in 14 patients (Zenith®；5 cases, Excluder®；9 cases) and was compared with open surgery in 15 patients. The medical fees of endovascular aortic repair and open surgery were 3,188,600 yen and 2,085,590 yen, respectively. The main reason for the higher fee of endovascular aortic repair is the graft cost. The material costs of endovascular aortic repair and open surgery were 1,853,500 yen and 251,330 yen. As a whole, the margin of profit of endovascular aortic repair was smaller than that of open surgery by about 1,500 yen/patient/day. Most patients undergoing endovascular aortic repair could walk and take oral intake from the first postoperative day, and the postoperative cost including infusion, medication, and labor was very small. With this convenience, the number of patients with abdominal aortic aneurysm increased 1.9 times after introduction of endovascular aortic repair.

We have developed a new management accounting system and have evaluated its effect. As a result of the new system implementation, the number of hospitalization stays has been shortened in some diseases which caused profit improvement. Further, with a reduction of excessive sickbeds, moderation in medical resource has been enhanced showing its impact.

Improvement and reduction in sickbed operation rate indicate profit increase trend and profit decline trend respectively and the fact that improvement of sickbed operation rate due to prolonged hospitalization stays under declining profit means profit decline were visualized.

These data were provided to diagnosis and treatment departments to be utilized as a management indicator for administratively effective hospitalization stay. In addition, standardization of medical care, improvement of patients' satisfaction level in regards to shorter hospitalization period, cooperation with local medical institutions and estimation of required number of sickbeds (medical resource) have been proved to be necessary in order to achieve the intended hospitalization stays.

In order to obtain fiscally effective hospitalization stay, 1. optimum bed number, 2. standardization of medical care, 3. increasing patient satisfaction in regards to hospitalization period, and 4. regional liaison, are necessary. This study indicates that “Providing efficient and high quality medical care to patients, medical institutions and society” is the most cost efficient, and that quality of care and quality of management can be balanced.

In Hyogo Prefecture, the inter-regional cerebral apoplexy critical path is developed and operated individually in each region; Kobe, south Hanshin, north Hanshin, east Harima, west Harima, north Harima, Sanda, Tanbasasayama, Tajima, and Awaji area. This time, an Excel-based inter-regional cerebral apoplexy critical path designed for use in the larger area was developed by collaboration given by north Harima, Sanda, and Tanbasasayama, south Hanshin, and north Hanshin. All patient data input (by doctors, nurses and rehabilitation staff) to this path are compiled to create at completion, diagnosis and treatment information letter, the nursing summary, and the rehabilitation summary. The path is designed to be utilized at both in the acute hospital and the convalescence hospital. Letter of introduction and midterm summary can be outputted at any time as every data is updated. Data can also be transcribed to an electronic data base. Since patient's essential information is already recorded at the acute hospital, it eliminates duplication at the maintenance period facilities and the convalescence hospital. It is also possible to exchange the critical path through Internet and E-mail if security can be secured. This inter-regional critical path may contribute to lessening the amount of administrative work-load.

In this study, we investigated apparent uneasiness among nurses regarding the operation of a syringe pump；and then carried out workshop-style training in groups of four, for the purpose of alleviating such uneasiness. We conducted a questionnaire survey both before and after the training with 122 nurses and evaluated the effect of using small workshop-style training.

According to the results of the questionnaire taken before the class, there were many nurses who felt uneasiness with 1.the flow quantity setting, 2.the method of the syringe set, and 3.the setting of the Oral Syringe System. In addition, the degree of recognition regarding the siphoning phenomenon and the Borlase injection was low. Many expert nurses felt uneasiness with the operation of the Oral Syringe System. Nurses not in the surgical ward felt more unease with the procedure. The results of the post-training questionnaire showed that uneasiness had decreased significantly for all aspects of procedure. And it showed that the understanding of the Siphoning phenomenon and of the Borlase injection had risen significantly.

The workshop-style small group training alleviated uneasiness with operation of the equipment and such training was considered an effective method for professional knowledge acquisition.