Appropriate cost estimation is essential to construct a reasonable medical fee system, where medical fees reflect cost. In this study, using basic management indicators we attempted to estimate the cost of inpatient and outpatient care at hospitals.

This study covers all prefectural hospitals in Japan and 50 member hospitals of the All Japan Hospital Association (AJHA). To find management indicators for the prefectural hospitals, we referred to the annual financial reports of local public enterprises released by the Ministry of Internal Affairs and Communications. Of the 226 AJHA member hospitals, 50 hospitals agreed to submit their accounting data of fiscal year 2008.

To estimate the cost of medical care, this study used hospital costs categorized according to major expenses, the average number of patients per day (inpatient and outpatient), the monthly average salary of employees, the number of staff of each profession, and others. Costs were subdivided into the costs for inpatient care, outpatient care, the central service division, and the indirect services division by using step-down accounting.

The estimated cost of inpatient care per patient was 42,686 JPY at prefectural hospitals and 27,443 JPY at AJHA hospitals. Outpatient care cost per patient was 15,611 JPY and 10,674 JPY respectively. Logistic regression analysis suggested that the profitability was related to the larger number of beds, higher average number of outpatients per day, and a higher utilization rate in general beds.

In July 2008, medical administrative staff was introduced to the orthopedic surgery department of Chiba Rosai Hospital. The effects of this introduction were evaluated from the aspects of improvement in clerical work and reduction of clerical workload on physicians. Improvement in clerical work was evaluated by comparing the following numbers before and after the introduction of medical administrative staff：the “number of days required to issue a medical certificate” and the “number of days required to complete a hospital discharge summary.” Reduction of physicians' clerical workload was evaluated by examining the changes in “overtime of physician” and physicians' satisfaction level of clerical work by the administrative staff. The mean “number of days required to issue a medical certificate” was shortened from 4.6 days (before introduction) to 1.4 days (after introduction). The mean “number of days required to complete a hospital discharge summary” was markedly reduced from 12.9 days to 4.0 days. The mean reduction of physician overtime was 13.2 hours/month per physician. Overtime pay was reduced by approximately 600,000 yen per month for the orthopedic surgery department following this introduction. Furthermore, performance of the medical administrative staff was evaluated high, and the physicians were highly satisfied with this new addition. Introduction of medical administrative staff not only reduced the workload of physicians but also enabled smooth progression of clerical work.

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.

The preventive administration of the antiemetics based on manifestation risk level of nausea and emesis in chemotherapy is considered to be effective. In the Nagara medical center （NMC）, necessity index of the administration of granisetron and the dose level of the dexamethasone were set loosely. Therefore Chemotherapy committee reviewed the usage of the antiemetic in accordance with the National Comprehensive Cancer Network （NCCN） guideline.

In chemotherapy regimen for the tumor of respiratory organs registered in NMC, the antiemetics in 14 regimens of the registered 22 regimen were amended. In the amended regimens, we compared the medicine cost of the antiemetics with the estimated cost without amendment. As a result, the medicine cost fell by 49.5% a year. In addition, for a lung cancer patient treated with the 3week-docetaxel treatment regimen that excluded granisetron with the change of the antiemetic, we compared incidence of nausea and emesis before and after the change over a 1-year period. As a result, the increase was not shown in the incidence of nausea and emesis by deletion of the granisetron.

By selecting antiemetic appropriately in accordance to the guideline, medicine costs fell without letting the incidence of nausea and emesis increase, and we were able to reduce the burden on the patient.

In Kagawa Rosai hospital, various improvements were done on the critical path software to incorporate the needs of the medical staff since the introduction of physician order entry system in 2004, and the introduction of the electronic medical record in 2007. As a result, 504 critical paths are currently being used covering approximately 95% of the discharged patients, and the critical path has become an indispensable tool to daily clinical activities.

However, there are still areas in need of improvement and this time we have focused to amend the following inconveniences newly pointed out by the staff:

1) The record overview is larger than the current overview screen and needs to be scrolled.

2) The document currently used for patient explanation or education for medical staff is not co-related with each critical path.

3) Record of orders categorized outside of order-entry system is inadequate.

The amendments incorporated at this time are to set up：1) block-calendar labeling, 2) related files index, 3) common clinical record.

This paper reports the effects of the above mentioned improvement to our critical path.

In Kagawa Rosai hospital, continuous improvement is given to the electronic medical record and electronic critical path systems configuration to make for easier and more staff-considerate use since the introduction of the order-entry system in 2004, and the electronic medical record in 2007.

Recently, execution of “team health care” had become indispensable in improvement of the medical quality． This time, "team clinical record" to enable inter-professional recording was added as a new function to the path. Nutrition support team, skin and excretion care team, infection control team, palliative care team, respiration support team, post-hospital discharge adjustment team, and the medical safety control team were added to the vertical item of the basic format of an electronic critical path as an item relevant to “team health care”,

We report of our findings of this new function.

Improper placement of nasogastric tubes results in severe complications. Although a two-step protocol of chest radiographs provides the only consistently valid and reliable evidence of the nasogastric tube position, the technique is too cumbersome to perform on a daily basis. In North America, researchers have begun using capnometry to verify nasogastric tube placement, but application of the same protocol in Japan is not possible because the equipment used in North America is not available in Japan. The purpose of the present study was to develop a protocol to verify nasogastric tube placement using the capnographs and nasogastric tubes available in Japan. The end tidal (ET) CO_２ curve based on the combined use of the Capnocheck Ⅱ and SAFEED Stomach Catheter provided 100% confidence for distinguishing whether the distal orifice of the tube was located in the lower pharynx or in the stomach. Connection of the tube and reading of the ETCO_２ curve required less than 1 minute to accomplish. This method is both simple and reliable enough to perform on a daily basis.