We have used the surgery-based critical paths for the cases of cervical cord injuries in our hospital. This path has several characteristics which are divided into preoperative course for the emergency operation with the postoperative rehabilitation, and furthermore, are classified by the level of injury of C5 or above and of C6 or below, considering the possibility of respiratory disturbances. Based on our experiences of these injuries, we revised the path so that health care providers can easily share information of these patients, thereby understanding the extent of cervical spinal cord injuries. We evaluated 9 patients that suffered from the cervical spinal cord injury (ASIA A or B) from 2007 to 2013. The clinical records were investigated retrospectively. Results suggested that mental support such as intervention of medical social worker and allotment of the palliative care team in the early stage after cervical cord injuries were important in these cases. Therefore, notice entry for prognosis of handicap and regular conferences were added to the existing path and Fink's crisis model was also applied. We believe that these critical paths are much useful for both patients and health care providers in the treatment of cervical cord injuries.

Promoting Inter-Professional Work is essential to construct the Integrated Care System. Conference of Palliative And Home Care (C-PAHC) was established at Kita Tama district in 2009 to hold lectures on enhancing inter-professional collaboration. The purpose of this study was to investigate the effect of our lectures on Inter-Professional Work by using “scale evaluating the quality of communication and cooperation among medical, nursing, and welfare services in a region (SCC)”.

75 individuals participated in this study. According to the SCC score, we divided these subjects into three groups as follows；“participated in lectures held by C-PAHC more than 6 times over the past three years”, “participated in inter-professional collaboration lectures not only C-PAHC but including others more than 6 times over the past three years” and “participated in inter-professional collaboration lectures less than 6 times over the past three years”. We performed Kruskal-Wallis test to compare between each group, and differences in mean values were assessed with Scheffe multiple comparison procedure.

We excluded one subject whose ratio of missing values was more than 15%. Therefore, the current study population consisted of 74 subjects. The median SCC score of “participated in lectures of C-PAHC more than 6 times over the past three years” was significantly greater than other groups. (P＜0.001, respectively)

These results indicate that participating in Inter-Professional Work lectures held in the district more than twice per year is recommended.

Iwate Prefectural Kamaishi Hospital is located in Kamaishi City, which is within the disaster area of Great East Japan Earthquake of 2011, and the only regional core hospital in Kamaishi medical area with 272 beds.

In our Hospital, the number of doctors have been decreasing. After the earthquake, the decreasing speed has been accelerating. In December, 2014, there were only 18 full-time doctors.

Iwate Medical station employed 4 retired doctors (herein referred to as senior doctors) and succeeded in placing them to our hospital. As a result, a radiologist from 2012, an anesthesiologist from 2013, another radiologist, and a gynecologist were appointed from 2014. Their dedication to their new found role has proven to be a great asset to us and the medical function of our hospital has been improved.

Following the success of ours and other cases, starting in April 2015, Iwate Medical station has introduced a three-year employment program of the senior doctors as fulltime clinical staff. Iwate is the first station which has introduced such system in the Tohoku area.

We will report the work status of the four senior doctors.

Our hospital is an acute care hospital of 435 beds located in the southwest region of Ehime Prefecture. We provide hospital diet of about 1000 meals a day. By providing delicious, safe and highly-satisfying diet to the patients aimed at the improvement of their eating rate, we practice the nutritional care management.

We have introduced a new cooking system on the occasion of the renovation of the hospital in October 2008, and tried to develop a breakfast menu. By the introduction of new cooking system, the number of breakfast menu is increased, and the amount of vegetables served at breakfast has increased. In addition, it reduced the cost of food materials and enabled to be applied to low-salt diet. Also, there was a positive effect on patient satisfaction.

At the same time, kitchen staff strongly recognize this change as the system that enables safe meal preparation. It also led to the improvement of the working environment.

The new cooking system proved to be beneficial to both patients and meal provider. Its usefulness as the way to prepare hospital diet and also as the management method of food service such as the cost of food materials or the labor management of kitchen staff has been shown.

Information sharing in organization is an important task. From January 2013, Yokohama Medical Center has introduced in-hospital digital signage (the system which offers information using TV monitor connecting to network in nursing station or medical office, etc.) with purpose of information sharing with staff members and improving awareness. Information (contents) for narrowcasting is divided broadly into 4 parts；“number of patients in the whole hospital”, “number of patients clinical department-wise/medical ward-wise”, “goal achievement update” and “work communication”. In 1〜2 months after introduction, we conducted monitor questionnaire, identified problems and took countermeasure solutions. And in a half year after introduction, we conducted questionnaire for the whole staff, and surveyed the viewing frequency of in-hospital digital signage, awareness evaluation for number of patients in the whole hospital, high audience rating contents, necessity of in-hospital digital signage for own workplace, etc. As a result, in-hospital digital signage was thought to play a certain role in information sharing. Also, after introduction the number of patients increased greatly and substantial decline of the assessment rate. This indicated that narrowcast about number of patients and goal achievement updates by in-hospital digital signage contributes to improvement in staff's awareness.

Method to use in-hospital digital signage is not clear because there are very few cases introduced in medical institution. Regarding introduction, display panel and delivery will cost more, but only 1 person staff labor in the hospital (holding other work) is enough since work is not so much, and from the view of encouraging information sharing as well as improvement in staff's awareness, the effects of introduction can be considerable. In future, further modifications and new usage structures are required.

With an increase of notices and bulletins, a bulletin board at a consultation room often becomes messy and disorderly. To circumvent this situation, I contrived to use four iPads, each installed with an application software suitable for posting calendars, frequent information updates, less frequent information updates and operation schedules. These four iPads were magnetically attached onto a whiteboard using tablet holders. They provide an easy and smooth access to any information. Now I would no longer need a new calendar and can update any content at my office. Thus iPad that has so many application softwares, can be a useful digital bulletin board.

Relationships between clinical process and cost/profitability are inferred from a questionnaire survey to hospital managers. This survey was mailed to 1,585 acute care hospitals reimbursed by DPC/PDPS (Diagnosis Procedure Combination/Per-Diem Payment System), and response rate was 16.7%. It reveals that managers suppose the following four relationships：within the same DPC, cases with irregularly longer length of stay (LOS) are more expensive and unprofitable than cases with standard LOS；DPCs with considerable variation of LOS are more unprofitable than DPCs with small variation；within the same DPC with critical pathway, cases deviated from the pathway are more expensive and unprofitable than cases on the pathway；and cases of DPCs without critical pathway are more unprofitable than cases of DPCs with pathway. These results indicate that controlling clinical process with standardized protocol such as critical pathway is important for profitability management. In addition, these results infer the need of modifying medical reimbursement system to prevent hospitals which face a severe financial pressure from excessive profitability management. Since possible relationships between clinical process and cost/profitability are not empirically supported by financial evidence based on cost accounting, further study to verify managers' knowledge is needed.