In this study, we focused on chronic disease patients in clinics, and verified causal relationship between the skills of clinic staffs such as a doctor, a nurse, a medical staff, to patient satisfaction, patients' loyalty, and patients' intention to recommend, by disease types.

Observed variables of skills of clinic workers include “knowledge and technique”, “explanation of treatment” and “attitude towards patients”. Only a doctor's skill will include “reduction of mental pains” in addition to these three skills. Cardiovascular, endocrine-metabolic, cerebrovascular and orthopedic diseases are selected as disease types. Causal relationships are analyzed by Structural Equation Modeling by each disease type.

Subjects are community residents, aged 20-69, who have one of chronic diseases listed above and visit clinics regularly. The number of subjects is 541(37.0%).

The result of this study shows that skills of a doctor and a medical staff directly affect patient satisfaction. Patient satisfaction directly affects patient loyalty and, also, indirectly affect their intention to recommend. Specifically, doctor's skills have significant impact on patient satisfaction, whereas nurse's skills do not have any influence on patient satisfaction.

An analysis of disease types shows that significant effects to patient satisfaction on loyalty in orthopedic disease are not obtained and effects of medical staff skill on patient satisfaction in cardiovascular are not obtained.

As for doctor's skills, “attitude towards patients” is the highest skill in cardiovascular diseases, and “reduction of mental pains” is the highest in the other three diseases, whereas, for medical staff skills, “attitude to patients” is the highest in all diseases.

This study aims to identify work-related stress factors in nurses employed at nursing homes for the elderly and to clarify relationships between work-related stress factors and burnout. We conducted a questionnaire survey of 1,000 nurses employed at nursing homes for the elderly throughout Japan by mail. As a result, the following six factors were extracted as work-related stress factors：“quantitative and qualitative workload,” “communication with residents/families,” “interpersonal relations in the workplace,” “multidisciplinary cooperation,” “relationships with doctors,” and “difficulties in addressing situations.” Cronbach's coefficient α values ranged from 0.524 to 0.852, suggesting that results were reliable. Among work-related stress factors and burnout subscales, associations were noted between “quantitative and qualitative workload” and “emotional exhaustion” (odds ratio, 3.464), between “interpersonal relations in the workplace” and “emotional exhaustion” (odds ratio, 1.647) or “depersonalization” (odds ratio, 4.502), and between “communication with residents/families” and “personal accomplishment” (odds ratio, 1.573).

These results suggest that nurses employed at nursing homes for the elderly are at a high risk for burnout due to work-related stress. As these results may have been affected by the state of nursing home residents and workplace environments, methods of reducing work-related stress need to be investigated to prevent burnout in nurses at nursing homes for the elderly.

The number of patients with prolonged hospitalization had not yet been expectedly decreased, although medical social workers and nurses of the coordination team for patient discharge are involved. Therefore, we modified the listing system of the patients who need plans for earlier discharge on the regular basis, because we need information as effective as possible. To consider patients for early discharge, the team listed the patient who might be hospitalized for long period, based on the information of the patients who had stayed for a prolonged period in our hospital.

The patients hospitalized over 20 days were extracted and the team investigated the information of delay factors of each patient on a weekly basis. As a result, we obtained the appropriate timing to assess the period of stay for each patients and awareness among the floor staffs for the support and the coordination of patient's discharge. Ten months after the commencement of the modified listing system, the number of the planned discharge support increased up to 164, and the number of patients hospitalized longer than 30 days decreased by 62. The listing system was a useful medical information.

Guidance on meals and chewing is needed along with medication counseling at community pharmacies participating in the integrated community care system. We conducted a questionnaire survey into the potential of pharmacists and registered dietitians cooperating for the purpose of producing high quality guidance for patients. All participants belonging to the FORALL Co. Ltd. answered the questionnaire. 27.8% of pharmacists and 52.6% of registered dietitians conducted nutrition counseling in the course of a week at our pharmacies. These results showed that the system promoting cooperation between these professionals is important and necessary because the availability of home consultations with registered dietitians is limited.

Nurses who often detect errors in medical practice are highly esteemed for their capacity to prevent medical accidents. The aim of this study was to identify characteristics of nurses in psychopathic hospitals who can detect errors during medical practice, both their own and those of others. Anonymous questionnaires were distributed to 217 nurses in two psychiatric hospitals whose working career was three years and longer (psychopathic group) to collect information regarding experiences in detecting errors of one's own making and errors of others during medical practice, the actual experiences of making errors, social skills, a safety climate in the wards, and general characteristics of the participants. The valid response rate was 75.6%. The control group consisted of 164 nurses in 11 general hospitals whose working career was three years and longer. Multiple logistic regression analysis was performed to determine factors related to experiences in detecting errors. In the psychopathic group, 76.8% had experienced detecting their own errors. This rate was higher than the control group (70.7%). In the psychopathic group, 87.2% had experienced detecting errors of others. This rate was same as the control group. In the psychopathic group, significant factors related to the experience of detecting one's own errors were：having experienced the clinical errors and a medical accident. Significant factors related to the experience of detecting errors of others were：the managerial position and low Advanced Skills, one of the subscales of social skills. To promote the measures for safety in the psychopathic hospital, it is recommended to utilize the experience of errors or accidents and to share the safety conscience that the nurse in the managerial position has across all members in the ward.

Pneumonia became the third leading disease-caused death according to the survey of the Ministry of Health, Labour and Welfare conducted in 2011. It was reported that more than 50% of hospitalized cases of pneumonia were aspiration-related. In our center, there were a lot of patients who suffered from this particular condition of aspiration-related pneumonia. Therefore, in 2014, a deglutition team was organized to study aspiration-related pneumonia with the hopes to prevent it.

First, we included the number of patients of past aspiration-related pneumonia. From that result, the alliances with regional welfare institutions and our center were very crucial to the prevention of aspiration-related pneumonia. In addition, in our center, the evaluation system of oral care was insufficient. Based on these problems, we carried out 1) the creation of the flowchart based on the intraoral evaluation scale, 2) the holding of the deglutition study session with the regional welfare institutions, and 3) the survey for dysphagia in the special elderly nursing home. As a result, the extraction standard of the patient who needed oral care became clear by the flowchart based on the intraoral evaluation scale. The members in the regional welfare institutions were enlightened by the deglutition study session. It was recognized from the survey that the needs for a specialized deglutition evaluation was high. As well as our center, we will start a concrete action for the prevention of aspiration-related pneumonia based on regional alliances in the future.

Combined antibiotic treatment with amikacin (200 mg/day) and minocycline (100 mg/day), which substantially have anti-bacterial action against methicillin-resistant Staphylococcus aureus (MRSA), was introduced as the first line therapy for infectious diseases of the bedridden elderly at home, and its effectiveness has been clinically evaluated in the tsunami disaster area. For the past three years, 113 cases out of 292 out-patients (ages；45〜105 years old, average 85 years old) caught bacterial infectious diseases, and total of 324 infectious events were treated with the combined therapy by 1〜2 weeks home visits. Respiratory tract infections including pneumonia (202 events, 62%) and urinary tract infections (105 events, 33%) were the most common while biliary tract and skin infections and enterocolitis were occasional causes. In the case of respiratory tract infections, the first line therapy (AMK + MINO) was successfully administered in 151 events but was changed in 51 events because of no apparent improvement of clinical symptoms (11 cases), the detection of drug-resistant bacterial pathogens (24 cases) or drug-induced allergy (1 case). The major clinical pathogens with the drug-resistant nature were MRSA (9 cases) and Pseudomonas aeruginosa (5 cases). Amikacin and minocycline accounted for 75% of the administered antibiotics in our out-patient clinic where no MRSA has been detected for more than 14 months to date. It is suggested that combined antibiotic treatment with amikacin and minocycline is a useful therapy for not only health care-associated pneumonia but also MRSA infection among elderly people at home.

The role of the pharmacist in the hospital ward is becoming more demanding. However, many hospitals have insufficient number of pharmacists to meet the demand resulting from the addition of further work activities to conventional operations. In this hospital, a similar problem was encountered for the preparation of injection medications. We reviewed the preparation of injection medications to clarify whether improvements to efficiency could enable new work activities to be undertaken with the existing staff.

We retrospectively reviewed injection medication preparation activities with root cause analysis to clarify the problems, and identified issues to be fundamentally improved. Through standardization, improvements to efficiency, reviewing of the inventory management, and the use of quality indicators for prescription confirmations, we reduced the injection medications preparation team from 27 to 18 pharmacists, thereby facilitating enough staff resources for additional work activities. And inventory value decreased to 34 million yen and the number of inquiries increased from 776 in FY 2013 to 1999 in FY 2015.

The psychological vital sign (PVS© Mie-chuo MC） constituted with a self-regulation inventory (SSI), profile of mood states, a monitor-blunter style scale and a stress degree was used as indices to evaluate an individual psychological health state. On the other hand, the Ministry of Health, Labor and Welfare put enterprises employed over 50 employees under an obligation to recommend using a simplified questionnaire for occupational stress. In the present study, the PVS self-check system was developed by modifying a profile of mood states to use this simplified questionnaire for occupational stress. Then seven hundred seventy-eight employees in the Mie-chuo Medical Center were inquired their mental health state in November 2016.

The results were separately analyzed to define the characteristics in 4 divisions, namely doctor, nursing, other medical staff and secretariat divisions by using one-way analysis of variance (ANOVA) and multiple comparison. Nursing division was characterized by the high social support and the low stress in working environment, however, the psychological quantitative and qualitative burden of work imposed on them were suspected to co-relate with the subjective physical sign, such as irritability, tiredness, anxiety and depressive state. A simplified questionnaire for occupational stress is better to judge the strength of stress, however, in the view of improvement of working environment, PVS including SSI might be one of the feasible self-check questionnaires providing with coping behavior.

We were using the psychological vital sign (PVS) defined with stress self-regulation inventory, profile of mood states (POMS), monitor-blunter style scale and stress degree, as mental health indices for nursing students and nurses who graduated school and were at work. In this study, a simple questionnaire for school life stress of nursing students (a questionnaire for school life stress) was developed by modifying a questionnaire for occupational stress of laborers which was provided by the Ministry of Health, Labor and Welfare. And the validity of constitutional concept of a simple questionnaire for school life stress as a substitute for a former POMS was investigated by using the 18 subjects of PVS and tested on 207 nursing students. Strong correlation was observed, and 3 causality models were generated by a structure equation modeling between a simple questionnaire for school life stress and POMS, namely, high degree of anxious feeling correlated with high degree of negative feelings, such as tension-anxiety, depression-dejection, anger-hostility, fatigue and confusion, and it also correlated with low degree of vigorous feeling. Moreover, the reliability coefficient of Cronbach's alpha for 18 subjects of PVS was revealed in high coefficient and the factor analysis represented that almost all the factors were corresponded closely with the measures. Good internal consistency and reliability of each factors were indicated. Strong correlation between a simple questionnaire for school life stress and POMS and their validity of constitutional concept were proved in this study.

Ministry of Health, Labour and Welfare of Japan introduced the Incorporated Administrative Agency system into National Hospital Organization (NHO), which was founded in 2004. The end of March 2014, saw the termination of two terms of five-year management plan in NHO. Each NHO hospital started to settle on management strategy for 5 years from 2004. In the 1^st term, NHO group reduced its capital investment and in the 2^nd term, NHO restarted to increase capital investment again. But they did not reduced the investment of personnel expense. As a result, they succeeded in the improvement of their financial state. In this study, we investigated the relation between the investment of personnel expenses and the medical profession incomes of all 143 NHO hospitals.

The financial statements of 143 NHO hospitals from 2004 to 2013 were obtained to investigate the financial conditions. We analyzed them with the analytical method which was based on personnel expense according to the classification of 6 groups which NHO classified their hospitals depending on their function and the number of hospital beds.

The 6 groups demonstrated that they increased the personnel investment per one bed. Two groups, especially, the hospitals offering acute-phase medical care with 350-500 beds and the hospitals offering acute-phase medical care with over 500 beds, had kept the continuous increase. These groups and the hospitals offering medical care for disabilities had maintained their medical profits. The group of hospitals offering psychiatric medical care, we observed the change in medical profit which was unrelated to the investment of personnel expenses.

The NHO strictly adheres to the management policy of a financial self-sufficiency, and they entrusted the management judgement of personnel and capital investment to the hospital director. As a result, it became possible to maintain a good financial condition in over 80% of NHO hospitals.

A revision to the overall added judgement was completed to evaluate the actions taken in anticipation of care services after discharge from the acute care hospitals. In Hospital A, the 2008 version of late-stage elderly health care revision had not yet been incorporated, I theorized that the introduction of the overall function judgement will construct a more comprehensive pathway of care from pre-hospitalization to home care after discharge, giving better chance of early discharge and above all security and comfort to the patients and family care givers.

The aim was to contribute to the hospital management by increasing the overall judgement assessment number. A project team was set up for early introduction of the system to design methods for a certain and early discharge. System-building and evaluation was done through workshops and information sharing using flow charts. Once the project started, the after reports and check sheets were examined to identify problem points and necessary amendments were added with each case. As a result, problems in discharge support was identified and further changes were implemented. Additionally, the need for intervention by the medical social workers (MSW) and discharge nurse was clarified. By creating a patient data base of pre-hospitalization to family medical history through hearings with the patients and their family members, nurses' overall work load was also lessened. With the new opening of pre-hospitalization support center in November of 2014, it allowed us to familiarize with the patients beforehand and made it easier to anticipate the type of home care after discharge. The project enabled us to provide better discharge plans for the patients.

In hospital A, we have implemented group training for the young and inexperienced nursing staff. However, we found that many of these nursing staff had uneasiness in using their technique. Therefore, we have been holding staff technical support club for the young and inexperienced nurses (hereafter referred to as “Hiyokko Club” ) since five years ago. By carrying out the evaluation of the “Hiyokko Club”, and to review the method of support so that we provide a better support, we conducted a questionnaire survey to 45 new recruited nursing staff in 2015.

As a result, it was ascertained that these new nursing staff considered the technical support of “Hiyokko Club” assertively and that the support built the staffs' confidence. Moreover, by participating in “Hiyokko Club”, the new nursing staff made friends and obtained mental support.

We found the “Hiyokko Club” as a meaningful place for the inexperienced nursing staff. To make “Hiyokko Club” more effective, it is necessary that we coordinate to continue holding and providing information including techniques menus. We have also obtained suggestion to improve on the types of support for the next year.