Critical pathway is nowadays used in various fields. In particular with the introduction of Diagnosis Procedure Combination (DPC) critical pathway has been implemented at hospitals more frequently. The Tokushima University Hospital introduces critical pathway into the electronic chart in January 2007 and this study evaluates appropriateness for and health outcome of the critical pathway as peri-operative management for lung cancer and its medical effect.
Out of 53 former cases between April 2005 and November 2006 this analysis included 38 non-complication cases (Non Critical Pathway group) and after a detailed study of their diagnosis and treatment results a Critical Pathway for lung cancer adapted for DPC was drawn up and implemented at the hospital.
For comparison a critical pathway was then drawn up for 30 cases from the period of June 2007 to May 2008 and of those, 24 non-complication cases (Critical Pathway group) were then investigated and compared to the former 38 cases. 6 cases involved complications with surgical procedures and were not included in the study.
Length of hospital stay in the Critical Pathway group was 14.7±2.7 days among II of DPC category, dominantly shorter than in the Non Critical Pathway group with 16.9±4.9 days.(p<0.024) Additionally antibiotics dosage periods were also shorter in the Critical Pathway group (2.5±1.3 days) than in the Non Critical Pathway group (4.1±2.1 days).(p<0.001) Inclusive income tended to be low in the Critical Pathway group compared to the Non Critical Pathway group.
The introduction of the Critical Pathway adapted for DPC at Tokushima University Hospital lead to a supply of uniform low cost medical treatment and, by attaching it to the electronic chart, to work related improvements for medical staff.

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Systematic measures offering safe medical treatment are important obligations in medical facilities and the risk manager (hereafter “RM”) is involved throughout the treatment process. Since 2002 securing a safety management systems in medical institutions is practically required. The number of serious accidents decreased in each medical institution, however, repeated small incidents still have not been eliminated. While larger hospitals nowadays have an education system for RMs in place, generally speaking, there is not much research on risk management in other hospitals.
The purpose of this research is to clarify the problems of the risk manager and the hospital environment surrounding the position.
The research was done by a question and answer survey and by a qualitative research through group discussion. Findings are that RMs are working for medical safety. However, they don't take proactive action to solve medical safety problems and to express the need of more support in various ways.
As a result it is necessary to support RMs in small and medium-sized hospitals by systematically providing sources of information and consultation. Additionally, exposure to various health professions and interactive studies are necessary to provide more background and education for RMs to allow them to become independent and able to take creative actions by themselves.

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This study aims to explore that how the use of a regional electronic medical information network between physicians and pharmacists has effects over their patients' medication adherence.
An electronic medical information networking system, characterized as asynchronous media and store-andforward techniques liberating users from temporal constraints, was implemented in the “S” district in Chiba prefecture. To examine the effects of the use of the medical network on adherence to medication among osteoporosis patients, a turnover marker of bone was compared between 179 patients on the network and 118 patients outside the network over a fixed study period, and additionally a questionnaire survey was conducted. Semi-structured interviews were also carried out with 21 pharmacists in order to reveal how they perceive the effects of the network.
As a result, the bone turnover marker significantly improved among the patients on the network as the medication period extended. Furthermore, interviews with pharmacists and the patients' questionnaire survey indicate that the use of the network ensured better communication, mutual understanding and trust between pharmacists and patients.
In conclusion, the network enables pharmacists to understand physicians' intentions better and consequently contributes to the improvement and knowledge acquisition of pharmacists.

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For any hospital it is important to estimate the medical revenue of each clinical division to decide on a proper management strategy. The Kyoto Katsura Hospital in 2003 introduced a system of Diagnosis Procedure Combination (DPC), which resulted in a new medical reward system. DPC-participating hospitals are required to create, retain and present files in the style specified by the Ministry of Health, Labor and Welfare (D, E, F files) for subsequent investigation. These files have a very useful data structure for evaluating hospitalization and medical status. We created a new accounting system for the estimation of medical revenue in each clinical division and diagnosis-procedure group. Furthermore, to evaluate and inspect the system developed in this study, we conducted a financial analysis of the Kyoto Katsura Hospital before and after introducing DPC. The result shows, that the sickbed operating ratio decreased from 86.9% to 75.0% by monthly comparison from 2005 to October 2006 and the sickbed turnover ratio improved from 1.6 to 2.0. Average length of stay decreased from 18.8 to 15.5 days. Daily hospital income per patient increased from 50, 540 yen to 53, 313 yen and material costs could be cut down 8.5% per year. As a result, financial balance of the hospital was back in the black by approximately 220 million yen in 2006 from a deficit of approximately 50 million yen in 2005. We studied and analyzed the remarkable medical revenue profile and came to the conclusion that the improvement of the sickbed turnover rate resulted in change of a hospitalization style and improvement of financial results.

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Many kinds of infusion devices are commercially available in Japan. In order to prevent medical accidents, the Juntendo University Hospital chose a closed infusion device made of polyvinyl chloride.
This study compares a complete kit and the manual preparation of closed infusion devices to clarify their efficiency and cost effects.
The study results show that using a closed infusion device kit reduces preparation time per single set from 96.1±22.4 to 55.8±12.0 seconds and per day from 97.0±22.0 to 22.0±3.0 minutes. This suggests that an introduction of a complete kit actually saves personnel work duration and in that sense expenses as well, however, the cost for using a kit was 1, 283, 424 yen more expensive per month than that for manual preparations.
Further analysis is required to clarify cost effectiveness in preventing medical incidences and catheter related infections in clinical settings.

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In November 2004, HOPE/EGMAIN-EX (version 4.5), an electronic medical record system developed by Fujitsu was introduced in the Tokyo Metropolitan Ohtsuka Hospital. Since then, the numerous critical pathways in the hospital have been integrated into electronic medical records. However, until date, neither have the variance analyses using HOPE/EGMAIN-EX been performed nor have the variance values been recorded.
In this study, we examine the cause of delay in analysis as well as the issues that arose while analyzing and labeling the variance values. The cumulative variance method was used to analyze 243 cases of cardiac catheterization performed between November 2004 and September 2006. The total variance was 1941 (8 per case), and the actual variance labeled was 70 (3.6%). The highest variance (1196) was observed in the category “additional inst ructions from the doctors, ” followed by “complications”(283) and “disregard and/or omitting the path by doctors”(219).
Since October 2006, additional measures have been taken to encourage the staff to have a better understanding of and to record the variance values. Following this approach, variance records have significantly increased. Therefore, it can be assumed that the lack of understanding of variance analyses and the differences between the critical pathway management tools on HOPE/EGMAIN-EX and those managed on paper were the main reasons for the former low recording. Moreover, failure of consensus among the staff regarding categorization of variance items was also considered one of the causes.

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At the Osaka National Hospital the day on which to extract an epidural anesthesia catheter is decided via a critical path. However deviation in the chosen day and problems with postoperative pain control suggested problems with the current critical path. To research these problems a survey questionnaire on pain control was prepared regarding six critical paths, including of the upper gastrointestinal tract, lower alimentary canal and laparoscopic cholecystectomy, which were carried out with postoperative pain control using epidural anesthesia. Results showed that patient satisfaction with laparoscopic cholecystectomy for pain control was high, that pain score and additional frequent use of painkiller were low and that complications overall were also low. On the other hand, regarding the other critical paths, patient satisfaction towards pain control was low, frequent painkiller use was high and pain score was also higher. Moreover, when the pain score was over “3” more than half of the cases required additional painkiller the extraction of an epidural anesthesia catheter was overdue in many of these case, and use painkiller increased after extraction.
In regard of these results the management methods in all critical paths other than laparoscopic cholecystectomy was changed by varying the quantity of epidural anesthesia and by extending the setting of the day when to extract the epidural anesthesia catheter. Afterwards the same questionnaire as before was given again and validity was verified.
As a result, although there was no big difference in the pain scores and the frequency of painkiller use compared to the results before the revision, patient satisfaction increased afterwards. Therefore, as a revision based on the results of variance analysis and postoperative pain management improved, the validity of the revision could be verified.

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As Japan moves into an aging society rapidly, the number of hip fractures continues to increase steadily. Therefore a liaison critical path for hip fracture treatment is already established widely in Japan to maintain a local healthcare system. 603 hip fractures were treated surgically at Ashikaga Red Cross Hospital over the peri od from January 2004 to May 2008, and the liaison critical path was applied to 26 hip fracture patients since November 2007.
In this study length of hospital stay and rate of home return were evaluated comparing the cases before and after the introduction of the liaison critical path. The length of hospital stay was 38 days before the introduction of the liaison critical path and the period was reduced to 32 days after the introduction. The rate of home return was 42.1% before the introduction and 33.7% afterwards. Since 31.5% of the patients were transferred to rehabilitation institutes afterwards, the real rate of home return is estimated at 65% after the introduction of the liaison critical path. Because 18 out of 144 patients, who were treated in 2007, were re-fractures, one important future issue for hip fractures is treatment of osteoporosis. The liaison critical path for osteoporosis treatment, which contains medical nutrition, medication and exercise therapy, is already established, but not yet widely in use due to low compliance of attending hospitals and clinics.
But we believe that the implementation of a local healthcare network combining the liaison critical path for osteoporosis treatment with the liaison critical path for hip fracture treatment could lead to a reduction of hip fractures.

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The Asahikawa Red Cross Hospital introduced a new regional medical cooperation system, which allows physicians at other medical institutions in the region to access clinical data in the electric medical record system of the hospital by using a safe internet connection. Broad bands such as an optical line or ADSL are necessary to communicate heavy information promptly. To guaranty security and for data encoding the Secure Sockets Layer-Virtual Private Network (SSL-VPN) was adopted. Access control is managed through a firewall.
Access to this system is regulated by prior registration and the use is limited to 1 year. Physicians can only refer to the data of their own patients. Any data stored in the electronic charts regarding the patient's diagnosis and treatment from when the chart was first established is available, for example appointment data, radiation, endoscope, and supersonic wave images, reports, summaries and information on prescription, drug administration and surgery. Institutions can also follow up on patients whom they introduced to the Asahikawa Red Cross Hospital.
Because the system addresses a variety of information collection, it is thought that it contributes to quality improvement of the regional cooperation on health issues.

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This research study examines the relationship between the mental and physical health and lifestyle of nurse graduates for the purpose of improving their mental health. Data was collected through a paper questionnaire survey from 97 newly graduated nurses who are employed at a hospital in West Japan.
Recently problems regarding the mental health issues and a high workplace turnover have been on the rise among nurse graduates. Related publications suggest that good physical health and lifestyle help to improve mental health.
The results of the questionnaire show that the depression tendency among these young nurses was 81%, even though their lifestyle and physical health were almost comparable to women in the general workforce in their 20th.
As relevant lifestyle choices having a good influence against depression issues the following choices were found: living with the family, good eating habits, consultation and physical exercise in regard to coping with work related stress, physical exercise as well as listening to music on days off.

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Medical treatment fee amendments caused an approximately 10% income decrease for the Department of Clinical Laboratory at the Saiseikai Matsusaka General Hospital in April 2004. The department therefore introduced 3 measurements to aim towards expenditure reduction and an earning increase.
1) The sets for the biochemical examination blanket items were improved; namely, screening sets for internal medicine were reduced from 18 to 16 items and the sets used in coronary angiography critical path were modified.
2) The fibrinogen and fibrin degradation product (FDP), which is a diagnosis and treatment fee demerit item, was deleted from the screening set of the departments of surgery and neurosurgery.
3) Examinations on ferritin and glicoalbumin, which were formerly outsourced, were conducted again in the hospital as emergency tests.
After the introduction of these measurements, income increased by about 1.66mill Yen over the following oneyear period.
The income increase was smaller than the income decrease caused by the medical treatment fee amendments. However, by reducing the biochemical examination blanket item, waste of reagent was avoided and costs reduced. Furthermore the cancellation of two subcontracted examinations contributed to an improvement of patient services inside the hospital.

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Saiseikai Yokohama-shi Tobu Hospital in cooperation with community medical facilities created a regional cooperative critical pathway for cases of gastric and colon cancer based on the methods of administering anticancer drugs. The hospital mainly serves the Kanagawa ward and Tsurumi ward of Yokohama City. Every month regular study sessions on digestive diseases are held for these two wards with the respective medical associations. During these sessions, after exchanging opinions with both associations and acquiring sufficient consent, the regional cooperative paths were created.
Considering practicality, three types of paths, based on the methods of administering anticancer drugs rather than on the stages, were created. Type A is a path with no administration of any anticancer drug. Type B is a path of the administration of UFT alone and Type C is a path with the administration of either TS-1 or UFT/UZEL, which both require a blood test before administration.
Subsequently, a questionnaire was distributed to the medical associations of each ward in order to verify their willingness to participate in these paths. The questionnaires were distributed to 189 institutions and answers were obtained from 104 institutions. Of these 104 institutions, 90 institutions expressed a desire to participate in the paths, of which 60 institutions agreed to the administration of anticancer drugs.
Registration began in January 2008 and 86 cases have been registered so far. 41 institutions are participating. In detail: 38 cases from 26 institutions with Stomach A, 1 case from 1 institution with Stomach B, 5 cases from 5 institutions with Stomach C, 31 cases from 17 institutions with Colon A, 11 cases from 8 institutions with Colon B and 0 case with Colon C. After approximately 6 months into the initiation of these paths no cases regarding problems of cooperation have emerged so far and that 86 cases have been registered from only 41 institutions shows the practicality of the initiative.

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Task outsourcing has been increasing in hospitals in Japan and it is therefore important to engage the dispatched clerical staff in quality and patient safety.
For this study thirty clerks participated in a planned claim-and-complaint training course. The clerks were divided into groups of 6 and underwent 110-minutes training sessions. For evaluating purposes questionnaires were given out after the completion of the training. Efforts were made to maintain the quality of the training by preparing guidelines and teaching materials before the start. The objective of the training was to establish a positive attitude towards claims and complaints. During the training, efforts were made to make the participants feel relaxed (ice-breaking).
Answers concerning claims that were given before the training and again after the training were then compared. The main content of the training included 1) an explanation of the four major needs (functional/quality need, economic need, need to show respect and need for dignity), 2) explanation of how to deal with claims and complaints and 3) role playing.
The questionnaires revealed that 83% of the participants were dissatisfied with their past management of claims and complaints. All of the participants thought that the training was useful. The training therefore appeared to have achieved its objective.

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Current medical care as well as medication is based on a balance between safety and efficacy. In regard to this principle, in 1980 the “Adverse Drug Reaction Relief Service” was legally established. It compensates patients who experience serious adverse health effects caused by proper use of drugs.
After having gone through several transitions, the Pharmaceuticals and Medical Devices Agency (PMDA) currently supports the Ministry of Health, Labour and Welfare (MHLW) on receipts of applications and payments to applicants. The Committee on Adverse Reaction and Infection Evaluation under the Pharmaceutical Affairs and Food Sanitation Council of the MHLW judges whether an application is covered by the service from the perspectives of medical and pharmaceutical science.
However, a recent increase of applications from patients has extended the period from the receipt of the application to the start of benefits. The PMDA has been working to address this problem and additionally conducted a fact-finding survey regarding health hazards caused by adverse drug reaction.
On the basis of the PMDA's work and surveys, this paper describes how the service supports patients and health care professionals.

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