The liaison critical path developed in Kumamoto City was appreciated and has spread nationwide as it allows optimization of improvement of the quality and efficiency of the local healthcare network by creating a liaison critical path. I introduce the effect of a liaison critical path created by the Hip Fracture Seamless Care Society in Kumamoto City, prepared and managed on the basis of the necessary criteria for a liaison critical path and discuss its future.

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An inter-regional critical path of cerebral apoplexy is created and employed in the seamless care study society established in the central and western part of Kagawa Prefecture in November, 2005. Use of a common rehabilitation steps, a common appraisal various assessment method, and d a common language using the pull down menu, by an overall community, was decided in order to standardize the description of critical path. And then, the nursing postscript and the postscript of rehabilitation were abolished by the improvement of the written content to an inter-regional critical path. Activity of seamless care study society was useful to construction of the human network between multi-occupational medical persons.
Although an inter-regional critical path of cerebral apoplexy is employed smoothly at present, the following new correspondences are performed. 1) The seamless care study society was established in Takamatsu City and the East part in addition to the central and western part of Kagawa Prefecture, and the environment which establishes the use a common inter-regional critical path of cerebral apoplexy in whole Kagawa Prefecture was prepared. 2) The system which enables employment of the Internet using K-MIX (Kagawa Internet Medical Exchange) to which security was secured is under construction for easier data analysis and better use of soft mechanism. 3) A home inter-regional critical path was having been newly created. 4) In corresponding to the notice from the Ministry of Health, Labour and Welfare to all prefectures, software of an inter-regional critical path of cerebral apoplexy is reformed so that the index of cerebral apoplexy can be automatically extracted from the information inputted into critical path.

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In a cooperation effort of the National Yokohama Medical Center Hospital (NYMCH) and the Saiseikai Wakakusa Hospital the regional cooperative critical pathway was applied to postoperative gastric and colon cancer patients of 33 clinics (153 patients) and 3 other clinics (5 patients), respectively. Of the 153 patients treated at the NYMCH, 7 were diagnosed with recurrence. Of these 7, five patients were diagnosed at cooperative clinics. Through a patients' questionnaire we found that the introduction of regional cooperative critical pathway shortened waiting time by 57 minutes, actual stay time by 105 minutes and commuting time by 31 minutes on average. Regarding diagnosis and treatment remuneration the hospital received 1179 points (N=9) before the introduction of the regional cooperative critical pathway and 1931 points (N=10) after its introduction. Medical fee analysis between National Yokohama Medical Center Hospital and other clinics showed higher fees at clinics than at the hospital. But, if the intangible benefits such as clinic/hospital stay and commuting time are taken into account, the individual expense by some patients might be cheaper at the clinics.
The numbers of re-visiting outpatients decreased after the introduction of the new system, on the other hand, the number of gastric and colon cancer patients for operation increased after the introduction. The regional cooperative critical pathway for postoperative gastric and colon cancer patients may have some advantage for the individual patient, the clinics and hospitals.
In the future, an even better chemotherapy and pain control is desired as well as the introduction on an electronic regional cooperative pathway.

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In 2004 a cooperation critical pathway for patients after coronary intervention was developed with the advice by the cardiologist at the regional medical center. Experiences with it were reported at a regional cooperation conference, and it was decided that this critical pathway should be introduced to other clinics in the area. Currently it is used at thirty clinics in Hamamatsu city.
From February 2004 to July 2006, 60 patients in the age group of 70.8±10.0 years were followed up after successful coronary intervention and discharge from the hospital; of these patients 50 were men and 10 were women. 18 patients had been diagnosed with acute myocardial infarction, 21 with unstable angina, 20 with effort angina and 1 with non-symptomatic myocardial ischemia. Anti-platelet therapy without side-effects could be continued in 85% (51 of 60) of the patients after three months and negative findings in stress electrocardiography were found in 90% (54 of 60) of the patients after six months. Patients without ischemic findings in stress cardiac scintigraphy or revascularization were 88% (47 of 53) after one year.
This study shows that the critical pathway is beneficial for physicians' diagnosis and treatment and at the same time is useful for the follow-up of patients after coronary intervention.

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[Purpose] The administrative reform in 2006 cut down on payments to care hospitals and as a result might increase dropouts from the long-term care insurance (LTCI) system for the elderly in Japan. The capacity reduction of the LTCI is believed to extend the length of stay in DPC (Diagnosis Procedure Combination) managed hospitals for the medical care of disabled patients, who commonly have additional complications that increase medical costs. This study analyzes how ADL (Activities of Daily Living) affect the management parameters adjusted with DPC.
[Methods] This study was conducted between July and November 2006, and included 2058 patients aged 15 or more who had been discharged from the Ureshino Medical Center. ADL scores of the DPC evaluation were converted to the Barthel Index (BI) in 0 to 100 points. We defined “disabled” as BI 60 or less, and correlated disability with the length of hospital stay and financial DPC ratio.
[Results] The studied elderly patients rated frequently as disabled. Disabled at discharge were 2.9% in the age group 15 to 64 years, 10.3% in age group 65 to 74 years, and 26.5% in age group 75 years or more, which correlated with the frequency of cannot-go-home in 4.4%, 9.4%, and 24.6%, respectively. Within the same DPC category, the disabled patients at admission had longer hospital stays and a lower DPC ratio. Multivariate analysis revealed that disability prolongs hospital stay by 2.57 days (95%CI 1.30-3.84), and reduces the DPC ratio by 0.047 (95% CI 0.020-0.067) after adjustments.
[Conclusion] Patients' ADL profoundly affects the parameters of hospital management. However, the DPC system does not properly compensate for profit and loss dependent on ADL. To avoid financial risks due to disability, DPC hospitals should make correct assessments and introduce strict ADL management for elderly patients.

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The aim of this study is to confirm the practice of efficient medical care by adapting our revised critical pathway to DPC. Seventy-nine patients with urinary stones, who were treated between September 2006 and February 2007 by using critical pathway of extracorporeal shock wave lithotripsy (ESWL), were investigated. Of those 79 patients, 63 were treated by using the pre-revision critical pathway (BR group) and 16 by using the critical pathway after revision (AR group). We also compared the fee for the treatment between the former payment system and the DPC reimbursement system in both groups. In addition we compared the quality, safety and efficiency of the medical care in both groups. In the BR group, the fee of the DPC reimbursement system was significantly lower than that of the former payment system. However, there was no difference between the two payment system fees in the AR group. Although laboratory and X-ray examinations as well as administration of medicine were retrenched, efficient medical care was performed without disadvantages to patients. Our results suggest that for pursuing better medical care quality and safety revision of critical pathways is necessary.

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The Gifu region has a population of around 800.000 people. In addition to the Gifu City Medical Association, five adjacent medical associations and multiple acute phase hospitals take care of the regions' population diagnosis' and medical treatments. If different critical pathways would be introduced at each hospital in the region, it would inconvenient primary care physicians. Subsequently in August 2006 the Gifu Healthcare Network Management Group was established to avoid this kind of situation. Based on the preceding regional medical network, this group includes doctors, nurses, medical social workers and clerks engaged in medical liaison at their hospitals or medical associations. The group's goal is to introduce a regional standardized critical pathway.
The group's members verified the intentions of the medical specialists of each hospital and reached an agreement to design a liaison critical pathway for chronic viral hepatitis and acute myocardial infarction.
Following this decision, disease specialists of both diseases and critical pathway design experts joined the group, which was further on divided into two working groups for liaison critical pathways according to the diseases. Subsequently, the pathways for both diseases were compiled in a standardized format under the name of ‘Gifu Area Medical Association Liaison Pathway (GAMALP)’, and were widely opened to primary care physicians in the Gifu region in May 2007.
The GAMALP aims to control both diseases and detect any abnormalities early on, as well as to implement a secure practice of the role-divided healthcare and medical standardization.
The two working groups will continue to examine the usefulness of the pathways, and the liaison network group will support the full implementation of the pathways and maintain regional partnership.

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For the purpose of patient-oriented medical treatment, the Critical Path Committee at the Fukui Prefectural Hospital revised and improved the critical pathway of cardiac catheterization by including patients' opinions and demands.
Materials and methods: We investigated the problems of the present critical pathway from 50 cases. The largest problems found were 1) small size of the letters on the sheets and difficult medical terms and 2) insufficient explanations by the nursing staff. Therefore this critical pathway was revised using larger letters and easier expressions. In addition, patients were asked to participate in explanations, affirmations and the clinical outcome of the critical pathway by using self-assessment check sheets. Among 50 patients who used the check sheets, 38 patients (76%) were satisfied with the new method. There were also negative comments by patients.
Conclusion: Self-assessment critical path check sheets are useful tools in patient-oriented medicine and lead to medical safety. A future topic will be the application of check sheets that respond to the individual patient.

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This study analyses the medical safety management at the Inba Pediatric Emergency Clinic, a primary emergency care center for children. This clinic is run by various staff from different affiliations and does not include any full-time staff. To raise the medical staff's awareness a medical safety management office was established as well as obligatory report compiling and workshop seminars, but a lack of recognition among physicians was identified as a most critical problem. This study suggests that further efforts to enhance multidisciplinary care are necessary. Fortunately, no medical accidents or incidences of malpractice have occurred to date. However, further measures, including resolution of incidents and problems, should be better identified in the reports.

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The Ube Rehabilitation Hospital is a 435 beds geriatric medical care hospital offering medical care to elderly patients with physical ability restrictions who need medical nursing treatment on a daily basis. Falls occupied a significant portion of the reported medical incidents and accidents, and physical inactivity and cognitive disorder of the patients was considered to be contributing to falls. We created a flow chart to classify the risk of falls, which is composed of 7 levels based on the ability to take a standing position, to move and cognition. Then we investigated the relation of a flow chart level and a falling. Consequently, it became clear that the ability to move unstably and cognitive disorder were related to the risk of falls.
In this study, we analyzed the relation of the falling and factors such as sex, age, a flow chart level, a degree of independence and medications. It turned out that the factors of 65 or more years old, flow chart level 1 to 3 which meant unstable move and cognitive disorder, a semi-bedridden state and the medication of muscle relaxant were related to falls in our hospital.
Base on the findings, we are to develop the assessment scoring system to predict the risk of falls and preventive ways taking each patient state into consideration.

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To eliminate incidents and accidents in the hospital's operation room on site as well as patients, the Japanese Red Cross Nagoya First Hospital introduced a new tabular checklist. The practice of staff changing into slippers before entering the operation room was disbanded and patients are also allowed to walk into the room themselves. The basic perspective of the new improvements between the operating room and the wards is to adopt continuous measures from the viewpoint of the patients. This has been achieved in cooperation with the hospital's infection prevention team and medical safety control committee as well as in reference to the experience and knowledge of other medical facilities. Surveillance of surgical site infections (SSI) after the introduction of the new management improvements revealed, that SSI did not increase, but actually decreased after the infection prevention team started to administer antibiotics intra-operatively every three hours. One incident-accident report was filed during the investigation period however serious disadvantage to the patient could be avoided by this management and the system proofed to work effectively. Currently our hospital is working to introduce an electronic medical recording system, and we are trying to include the experiences made with the operation incident prevention measures to assure a high quality safety system.

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Since the establishment of the Palliative Care Team at the Chukyo Hospital in 2003, drug prescription quantities increased substantially. Nursing workloads also greatly increased accordingly, as well as time required writing reports concerning narcotic drug use.
The Chukyo Hospital had been using a narcotic prescription and a narcotic drug use report; each of them was a 3-copy set, but a new system now requires only 2 copies and 4 reproductions respectively. As a result the number of corrections to the reports decreased noticeable and the hospital was able to decrease the expenditures concerning drug prescription and reports by 2/3. In addition, according to a questionnaire targeting nursing teachers, the hospital was able to reduce nursing teachers' duties as well.

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