[in Japanese]

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Ileus refers to a lack or limited intestinal passage. During treatment of ileus, close observation of transition of symptoms and presumption of a cause are important to determine whether conservative treatment or a surgical operation should be selected.
Furthermore, in order to follow-up the various degrees of the illness or treatment procedures, it is difficult to correspond with only a single critical pathway.
Therefore four critical pathways were created at the Yamanaka-Spa Medical Center: 1) a ileus algorithm pathway for patients, 2) a primary care critical pathway for conservative treatment from onset to day three, 3) a conservative treatment continuation pathway from day four, and 4) a surgical operation pathway.
By combining short-term critical pathways, it was possible to provide critical pathways, which can respond according to a patient's condition. Moreover, this approach makes it possible to apply critical pathways to electronic medical records.

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In October 2005 Hakujyuji Hospital, a mixed-case type hospital (299 beds for acute-stage patients; 167 beds for recovering patients, ) introduced ward rounds for bed management to achieve “effective utilization of hospital beds”, Rounds were established at each of the hospital's 8 wards on a once in 4-week rotation base. A total of 9 individuals conducted rounds, including 5 members of the community medical section, 3 members of the hospital bed management committee, and a nursing manager from the ward. Surveyed patients included acute-stage patients, who had been hospitalized for more than 30 days, and patients already in recovery, who had been hospitalized for more than 3 months. A form indicating the reasons for the patient's long-term hospitalization by the physician in charge was obtained the day before the rounds. During the rounds, future medical proposals were suggested, and the progress status was verified again 1 week later.
The actual conditions of long-term inpatients were recognized by implementing the rounds. In addition, it was possible to facilitate awareness of the effective utilization of hospital beds among the hospital staff. In many cases the need of further implementation of medical care for patients were identified during the rounds and the process of transferring the patient within the hospital or to another facility, or discharging him/her from the hospital was initiated. During this project the number of cases in which physicians in charge voluntarily transferred patients within the hospital or to other hospitals increased significantly. Furthermore, the number of hospital discharge cases, which were postponed due to social adjustment problems, also decreased. It is important to ensure well-organized medical collaboration, and utilize hospital beds effectively in order to perform medical care activities that meet the needs of the community.

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In April 2005, one year after the automatization of the National Universities, a Regional Cooperation Unit (RCU) was introduced to the Hamamatsu Medical University Hospital. This unit appoints first time consultations to patients as requested by regional practitioners, and is responsible for offering information as to the open units to regional practitioners. After performing a market research concerning regional institutions, we reorganized the organization and information system at the hospital. For the newly created RCU, new staff was recruited and a hotline from regional practitioners was also introduced. Also, a data filing system to evaluate the trend of outpatients was newly established.
One and a half year after the RCU's establishment, the hospital experiences an increase of nearly 100 new outpatients per day as well as a 10% increase of referred patients. At present, 55% of all new outpatients apply by way of the RCU system. Moreover, although ALOS is decreasing to 18days on average, bed occupation rate is maintained at 80-85%. In conclusion, even though changing to a public corporation first seemed to be difficult for national universities, it turned out to be a challenge that offered great opportunities and continuous efforts seem to be important.

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Fall accidents of aged hospital inpatients have become an increasing problem as the average age of inpatients is increasing. In this study we examined the relationship between the score evaluated by the assessment score sheets of falling, the physical functional test and fall incidence among risk II patients. Our study shows that these three factors are related to the risk of falling. The Functional Balance Scale and the maximum walking speed for 10 meter were used to evaluate physical functions. We believe that by using this clinical evaluation it is possible to decrease the number of inpatients falling during their hospital stay.

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The most serious errors in transfusion therapy are mistransfusion and blood type incompatible transfusion caused by human error. In order to increase safety, the Juntendo University Hospital introduced a bar code verification system where blood products were verified using patients' wristband bar code. To evaluate effectiveness and possible problems of this system, we conducted a questionnaire survey asking medical staff, who had used the system, and patients, who had received blood transfusions, about their experience with it. Both parties evaluated the system as very safe. We concluded that the system gives a sense of security not only to patients but also to medical staff. It is useful for the improvement of medical services and medical staff support. In addition, operation improvement helped to decrease the return rate and scrappage rate of red cell components after the introducing the system. This study proves that the introduction of this system and the restructuring of the actual operation are effective ways to improve safety management helping to prevent human errors, and it is very profitable in the sense of improving quality of services for patients and proper use of blood products.

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With the progress of IT at medical institutions, electronic medical record systems, other related department systems and the number of masters and master databases are increasing. Masters for drugs (drug masters) in particular are related to almost all department systems, not to mention ordering systems and medical systems. And their inconsistency may pose a problem for the safety management as well as for the inventory management. Since the introduction of a new distribution system at Toyota Memorial Hospital in November 1999, we have unified the management of three systems using the master management tool: the distribution, the claiming and the ordering system. However, since the introduction of the electronic medical record system and other related department systems in September 2003, drug masters increased remarkable, and it was learned that, due to a failure of timely conveyance of master information to each department, the delay in master maintenance work interfered with the medical practice. In addition, the hospital aims for a new drug inventory management linked with the electronic medical record system and improvement in management accuracy is an essential task. Therefore, we completely improved the master management tool of the distribution system and changed the conventional operation with vouchers to an operation utilizing shared files in the hospital e-mail system and the hospital intranet at the same time. As a result total working hours and the number of days required before completion of registrations were substantially shortened. We also have now completed linkage with the dispensing system and will report about this step in the future.

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This study reports about the outcome of NST activities at Anegasaki Hospital, a small scale, long term care hospital. The NST activity was introduced at the hospital after participating in a NST project organized by the Japanese Society for Parenteral and Enteral Nutrition and has brought about remarkable benefits shown below. NST provides optimal nutritional prescription to each patient, and it has brought about a decrease in cases of invasive TPN and an increase in cases of EN in routine clinical activities. These changes additionally brought economic results, an increased revenue in reimbursement rates of health insurances up to June 2006. In EN, the number of patients with serum albumin level not more than 3.0g/dl decreased by administrating the appropriate amount of calories to each patient. Such nutritional improvement simultaneously resulted in a decreased mortality during admission and an increase in patients becoming able to orally eat food and consequently being transferred to the care center attached to our hospital. After starting NST, many patients, who were first bedridden and cared for by TPN or EN, became able to orally eat their food and some of them were even able to leave hospital in good physiological condition. In a hospital which used to witness high mortality rate, these changes are very welcome by the hospital staff.

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To understand the importance of medical records, our study team simulated the disclosure of medical charts. Residents, the general risk manager, a clerical staff, the person in charge of resident training program and the health information manager of Himeji Medical Center took part in this study. Modified real medical charts were used to protect patients' personal data. In role-play settings we took the part of applicants, physicians incharge and superior doctors, and concluded with a discussion about the writing of charts.
This method had much significance: 1. Recognition of the importance of medical records. 2. Residents learn the bases of medical recording. 3. Inspection of the content of medical charts. 4. Promotion of teamwork in medical treatment. 5. Preparation of true medical chart disclosure.
Furthermore we also held seminars, during which we judged the quality of medical record written by residents. In-house inspections have shown that residents record medical charts better than superior physicians. The simulation of medical chart disclosure proved to improve the quality of medical records.

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In a patient satisfaction survey, it may be better for the hospital to investigate what issues are most related to an overall patient satisfaction level than only focus on the average degree of satisfaction. Targeting 134 outpatients and 165 inpatients and using stepwise multiple regression analysis we studied how the 8 questions in a patient satisfaction survey were related to the overall satisfaction level. Waiting time, consideration for privacy and attitudes by nurses towards outpatients, as well as attitudes by doctors, cleanliness of the room, comfort of the bed and for hospitalized patients taste of the hospital diet were listed in the descending order of coefficient of regression. This order was linked to the overall hospital satisfaction level. Comparing the outpatients' and inpatients' survey results, the outpatients' waiting time had the highest regression and the lowest satisfaction level, indicating the need of prompter responses towards outpatients on the issue of waiting time. We should have the consciousness that patient satisfaction level is closely related to the hospital's management. And patient satisfaction surveys, that can reveal problems at the hospital, are especially important.

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On April 28, 2005 the Tokushima University hospital acquired the privacy mark certification in order to protect individual private information. The university hospital uses a variety of important individual information and there had been problems in its handling. Then, on top of executing private information protection, we reformed the existing compliance program (manual and regulations) to include all information related to a security solution. Because these introductions were introduced simultaneously, it was possible to train the hospital staff as well as subcontractors on these protective private information measures. Because of the sheer number of patients, whom the hospital handles, it will be necessary to make a continuous effort to further improve the compliance program in the future.

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In order to continuously improve the quality of medical care services, it is essential to utilize CIs (clinical indicators). However, the kind of CIs that is useful for our facility, and how it should be utilized to improve the quality of services was a major issue when introducing it to our hospital. Extracting the necessary data out of an enormous quantity of medical information and announcing them officially as CIs required a lot of time and effort.
In June 2005, after studying the necessity of CIs and adjusting it to the needs of the hospital, we submitted CIs to each division through top-down management. The Medical Information Management Division conducted hearings with each division. Information regarding CIs was provided and manageable data was introduced by setting definitions and goals for each CI. In order to decrease labor for the collection and analysis of data and to improve the efficiency in calculating CIs, electronic medical chart functions and the DWH (data warehouse) system were introduced. Since December 2006, 56 CIs are periodically calculated and this led to an increase of the use of electronic medical chart terminals by the staff of our hospital.
Furthermore, some evidences of the process index, that might have a major impact on the outcome index of the hospital, have been observed.

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To accomplish an effective and appropriate follow-up of patients with elevated level of serum prostate specific antigen (PSA) and negative test for prostate biopsy, a critical pathway has been proposed based on the regional healthcare network between urologists and primary care physicians. A questionnaire on the management of urological diseases including prostate cancer was sent to 48 primary care physicians in Ushigome Area, Shinjuku -ku, Tokyo. As a consequence of the analysis of the answers and discussion between urologists and primary care physicians, a regional cooperation critical pathway was prepared for patients with suspicious prostate cancer. Of 28 responders, 23 (82%) agreed to survey their patients with suspicious prostate cancer by measuring serum PSA level. Thus, a regional cooperation critical pathway was introduced, including screening of PSA during the primary care physician's urological examinations and, if required, prostate biopsy at a referred urologist, in case of negative test for biopsy, followed by a follow-up with serial PSA measurements at the primary care physician. When retuning to the primary care physician, interval of PSA measurements and criteria for re-referring to yet another urologist were indicated for each case by the urologist. In conclusion, a regional cooperation critical pathway for patients of suspicious prostate cancer established a regional partnership between primary care physicians and urologists thus enabling to offer appropriate care to patients with suspicious prostate cancer.

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