In Japan, about half of the citizens wish to die at home, but the majority of deaths occur in hospitals. The proportion of hospital death by cancer is especially high. If cancer patients wish to be cared for and die at home, it is important to realize their wishes. In this study, focusing on the presence or absence of home medical care before hospitalization, we examine measures to realize continuation of medical care and death at home by clarifying differences in treatment contents and period from hospitalization to death. With a retrospective cohort study design, we used the data derived from the Japanese administrative database and diagnosis procedure combination (DPC) database. In this study, 11,876 end stage pancreatic cancer cases were included. We compared differences in treatment contents and period from hospitalization to death by presence or absence of home medical care before hospitalization. As a result, patients who had home medical care before hospitalization had lower percentage of life-prolonging treatments such as cardiopulmonary resuscitation and active treatment such as chemotherapy. Also, patients who had home medical care had shorter days between hospitalization and death. Based on these results, it was considered that patients who had home medical care before hospitalization had decided beforehand not to be treated with life-prolonging treatment and active treatment. Also, it was considered that patients who had home medical care ware taken to the hospital and had died relatively soon after staying at home until just before the life crisis. If cancer patients wanted to be treated or to die at home, it was considered important to eliminate the anxiety concerning medical care of patients, and that of patients' families, to avoid hospitalization. To that end, it was considered important for medical staff to implement early palliative care and to carefully explain the condition to patients and their families.

We use surgical-based critical pathways for many patients with gynecological disease. Occasionally, however, adjustments in treatment are required for patients with complications or underlying diseases. We developed an optional pathway, which is implemented by our electronic record system and adds extra functions to the conventional critical pathways. In this paper, we describe the development of an optional pathway for standardizing heparin bridging in patients prescribed with anticoagulants. Multiple inter-departmental discussions were held in the creation of this optional pathway.

We have used this optional pathway in 9 cases so far. Using this pathway has standardized the way heparin is injected and the nursing instructions for heparin use in our ward. We have also written an information sheet for patients on heparin injections during hospitalization. The optional pathway has standardized and improved the medical care provided to these patients. On the other hand, we have experienced some problems, such as with the regulation of the activated partial thromboplastin time and outcome evaluations. After addressing these problems and altering the plan-do-check-act cycle, we consider that the optional pathway will be more useful than the conventional pathway.

This is the first optional pathway employed at our hospital. We could develop other optional pathways for patients with different complications or underlying diseases, and they might result in the provision of better standardized care.

In April 2016, the Japanese Society of Chemotherapy and the Japan Society for Surgical Infection issued practical guidelines for the appropriate use of antibiotic prophylaxis for surgical site infections. At the obstetrics and gynecology department of our hospital, a multidisciplinary working group was established to promote the appropriate use of antibiotic prophylaxis for surgical site infections according to the guidelines (hereafter intervention). To visualize the progress of the intervention, the discontinuation rate (a proportion of cases in which antibiotics are appropriately discontinued), appropriate antibiotic selection rate of resuming antibiotic therapy, duration of postoperative hospital stay and costs of antibiotic were calculated from the Diagnosis Procedure Combination (DPC) data. To assess outcomes that could not be measured with the DPC data alone, medical records were also reviewed to determine the incidence rate of surgical site infection (SSI), incidence rate of fever of ≥ 38.5 ℃ on or after postoperative day 3, rate of resuming antibiotic therapy, and duration of postoperative hospital stay. Antibiotics were more appropriately used and selected after the intervention and costs of antibiotic were significantly decreased. The other 4 indices of outcome assessment remained unchanged before and after the intervention. The use of the DPC data permitted quantitative assessment of the progress and effects of the intervention.

The balanced scorecard (BSC) is a strategy management tool, that can be used to keep track of the accomplishment of activities by the staff and to monitor the consequences arising from these actions. We adopted BSC as a management tool for medical safety activity from 2015. We set up quality indicators (QI) that are targets to be attained in BSC. In 2016, our own risk classification “ABC” was prepared to analyze incident reports regardless of impact level. Class A is a case to be prevented and Class C to be warned. Class B is neither A nor C. In consequence, number of incident report increased to 2639 (814 increase over the previous year). The ratio of incident level 0 to others reached to 30.8% (target value set in advance was 30%). We think the introduction of BSC and QI contributed to the promotion of medical safety activity in part through informing the staff with an objective target. These results suggest that BSC is a valuable tool for medical safety management.

In order to reduce the overtime hours of 182 full-time therapists employed in Hikari Medical Group, we implemented initiatives from August 2008 (hereinafter referred to as “the first survey”) to March 2007 (the second survey). Surveyed group were categorized into 4 groups：category A - new graduate, B - 2-years or more experience, C - leaders, and D - managers. Initiatives to reduce overtime work are 1) less than 5 hours of overtime/month, 2) classification criteria for overtime and self-study, and introducing the system of pre-application of overtime, 3) adjustment of the number of acquisition units for groups A and B, and, 4) holding study group during the working hours by the rehabilitation division. As a result, average overtime hours significantly decreased in groups A and B in the 1st and 2nd survey, achieving the initiative goal. On the other hand, groups C and D decreased overtime but did not achieve the initiative goal, and especially group C did not show any significant difference in the 2nd survey compared to the 1st survey. The efforts we conducted at this time mainly focused on how to use the time as a rehabilitation department and it was effective for A and B with little involvement with the other departments. Overtime factors of C and D are considered to be operational duties set outside of this effort, such as involvement with other departments, correspondence to patients and families, and support for A. Specifically in C, there is no significant difference in the 2nd survey compared with the 1st survey, and suggested concentration of work. Reducing the overtime hours is also necessary to ensure satisfaction with work environments, stress care, and re-allocate time for training for self-actualization. Further construction of measures to reduce the work load on group C should be considered.

The authors conducted a consciousness survey on job satisfaction of Health Information Managers (HIM). 113 cases were valid. The valid response rate was 71.5%. Contributing factors affecting job satisfaction were supervisor's approach and encouragement to their staff members, understanding of HIM roles from other departments, and recognition for HIM from staff members in other departments. While the relationship between each HIM and their supervisors showed a significant difference, the relationship between HIM and their colleagues and supervisees did not show significant difference in job satisfaction. Attempts for improvement of job satisfaction are that individual HIM get proactively involved with staff members in other departments and that HIM perceive other staff members, especially their supervisors, care about themselves. Also, it is necessary that HIM produce useful results for other departments, and that HIM create good human relations in the workplace where they can actively communicate both inside and outside the department.