As we believe customer satisfaction (CS) can be achieved by solving problems of customer, patients for hospital can be considered as equivalent as customers for non-medical companies. CS in hospital management can be subdivided in three parts. The first part is satisfaction of patients and patients' families. The second part is satisfaction of affiliated private clinics, medical facilities or nursing facilities, which is equivalent of dealers' satisfaction (DS) for non-medical companies. The third is satisfaction in employees (ES).
In Toyota memorial hospital, we consider these three parts of CS as most fundamental philosophy for hospital management. And the motto of “we are proud of our customers' smile with satisfaction” is listed first on our policies.
In general, the purpose of organization management is to assure quality of products or services. In the same way, the purpose of hospital management is to assure quality of medical care and subsequently achieve these three parts of CS.
For achieving CS, “policy management method” is applied in our hospital. In this policy management method, human resource development, which is how to improve employees' capacity, is involved as the biggest part. We introduce three specific examples of policy management for improvement of medical care in our hospital. The first is encouragement of trans-sectional activity. The second is arrangement of organ-based specialty center. The third is application of clinical indicator.

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The first aim of this study was to compare patients' satisfaction regarding discharge support between those who received support directly from the Discharge Support Section (DSS group) and those who were supported by the ward staff (WS group). The second purpose was to assess patients' evaluation regarding the DSS' support.
140 patients who were discharged between October and December 2006 and who were screened as having needed discharge support at the time of their hospitalization were included in this survey. They answered the modified Client Satisfaction Questionnaire-8J consisting of 16 questions.
Satisfaction degree regarding explanations on utilization of welfare services and instructions of care were significant higher in the DSS group than in the WS group. This suggests an important direct support by the Discharge Support Section.
In the DSS group, patients who received mainly “home care preparation” explanations assessed explanations of daily life, medical care, and action in an emergency after leaving hospital higher than patients who received mainly “supports for hospital shift” or “consultation regarding care and welfare”. A reason might be that “home care preparation” explanations are given to patients together with their family.

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The Patient Safety Training Course held by the National Institute of Public Health (NIPH) is a 6-month course that teaches the basic technical knowledge and skills of patient safety to trainees. The course includes lectures and practices regarding safety control, crisis management and quality management and is held annually from October to late December. During this period, the trainees are required to return to the hospitals they belong to for one week in order to put the contents of the course into practice and after returning to the course they are required present their results. The first 2 months of the year are then spent studying individually in regard to patient safety. In March, the trainees present their studies and organize them into research papers. The course is completed after submitting this research paper.
NIPH has so far reviewed 86 research papers over the past 5 years in order to study future prospects. During the initial phase of this course, many of the trainees took up patient safety systems for their individual studies, while the recent trend is in quality control systems. Risk management, patient safety training, and analytical method were also taken as themes of studies.
Since this training course is a long-term program, it is occasionally difficult for trainees to take the course because of their work schedule. Nonetheless, the advantages of this course are to enable the trainees to obtain various knowledge and techniques regarding patient safety, to comprehend the current state of patient safety in the hospitals they belong to through actual practices and to enable them to study their chosen study individually.

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In the case of an inadequate prescription dosage, medical risks are much higher when nutrition is administered parenteral than erental. The Kanazawa University Hospital experienced a case of chronic renal failure that developed into severe hypophosphatemia due to a glucose overdose while administering parenteral nutrition. A retrospective fact-finding study found that at this hospital the parenteral nutrition dosages containing HICALIQ-RF^® had the tendency for an insufficient dosage of amino. Furthermore, lipid emulsion had not been administered in that one case, and nutrition was mainly delivered as glucose. But energy needs differ widely for patients. The unified use of transfusions should help physicians find the suitable individual nutrition dosage without differences like that. In this sense it is meaningful that the hospital's Nutrition Support Team (NST) pharmacists, who do have the specialist knowledge, deliver accurate information regarding parenteral nutrition and prepare adequate individual dosages. Specialized nutritional therapies arranged by the NST not only results in the adequate use of transfusions, but also achieve beneficial and economically results for both the patients and hospital management.

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clinical results regarding medical accidents involving residual surgical gauze during surgery. Our strategy includes the use of an icecube tray and the establishment of a time-out protocol, which requires a gauze count during every operation. The ice-cube tray has 10 holes with a size of 40 × 38 × 30mm. Each hole contains only one piece of gauze. During surgery the nurse places each used piece of gauze into one hole instead of counting the pieces of gauze one by one as before. This procedure thus reduces the nurse's workload. For the “time-out” for a gauze count, the surgeons stop their procedures and place all pieces of gauze within the operating field into the holes of the sterilized tray.
To verify the results of this new strategy, incident reports regarding the gauze count were collected and evaluated over a period of more than 5 years, from October 2002 to September 2007.
1) There were 362 incident reports during this period. Among them were 12 reports regarding the gauze count, including 1 writing mistake on the gauze count sheet and 11 mismatches in regard to the gauze count.
2) All 11 mismatches indicated that a piece of gauze was missing. In all cases, the missing piece was later found at various sites including around the patient (5), in the operating field (2), or having been carried away with a frozen section or specimen (4).
3) In 8 of the 12 reported cases, X-ray examinations were performed before the wound was closed. There was no case in which residual surgical gauze was detected inside a patient's body.
4) There was no one incident of residual surgical gauze during the study period. Our above described prevention strategy therefore seems to be effective.

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In-house mediation is one form of Alternative Dispute Resolution (ADR) to manage medical malpractice cases. This ADR model encourages parties' amicable negotiation and creative consensus building with the help of an impartial in-house mediator who has effective mediation skills. This paper examines 26 cases in which mediation was conducted during the last two years at Toyonaka Municipal Hospital.
In most of the cases, 17, family members made the claim. In 22 cases the object of the claim was the physician. A variety of cases including death, permanent residual disability, temporal disability and even five no damage cases were handled. Causes of claims included problems in diagnosis, treatment, operation, explanation and observation.
Average mediation duration was 72.4 minutes with 80.8% cases successfully settled. 84.6% cases were settled within 90 days after the claim was filed and no lawsuit was filed.
In most cases the perception of healthcare professionals regarding cause or complication were in conflict with that of patients. In the process of the mediation this gap of perceptions, on one side based on medical knowledge and on the patients' side on everyday lay perspective, as well as emotional conflicts emerging from this gap were adjusted and early settlements were found. Moreover, the introduction of in-house mediations encouraged awareness in regard to organizational efforts to prevent the escalation of conflicts and it also had educational effects on the improvement of physicians' and staff's explanations and attitudes towards patients.

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In 2006, the Oita Oka Hospital decided to abolish the intracutaneous reaction test of antibiotics as a new safety policy.
After the intracutaneous reaction test's abolition allergy symptoms associated with an intravenous injection of antibiotics were found in 20 (1.22%) of 1640 cases. In one case (0.06%), which was administrated with vancomycin, an anaphylactic shock was diagnosed. In 10 cases glicopeptide antibiotics were given. The risk of anaphylaxis related to intravenous injection of antibiotics which don't require an intracutaneous reaction test, should be recognized. Appropriate intracutaneous reaction tests based on given guidelines should be carried out on patients, who need the test, while it is important to precautionary prepare a treatment for anaphylaxis and continue the patient's observation during the administration of antibiotics.

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This study investigates the primary care status of 3, 821 of the 5, 086 inpatients admitted to Nagahama City Hospital during September 2006 to March 2007. 69.3% of these inpatients who were admitted to the general medicine department, 64.8% of those who had cardiovascular surgery, and 63.3% of those who were admitted to the ophthalmology department, answered that they had a primary care physician. About half, 54.6%, of those inpatients actually had primary care physicians. 73.6% of those who answered that they had no primary care physicians, did not expect to have one in the future either. 94.5% of the inpatients who were referred from primary care physicians answered that they did have one. 44.6% of the inpatients without referral answered that they had a primary care physician, and 57.6% of them wanted to be referred to a primary care physician with their medical records.
As a result this study suggests that reverse referrals back to primary care physicians should be promoted further in future.

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Recently, many critical pathways are drawn up using spreadsheet type software. Although a spreadsheet has various functions, it is usually used only for printouts. But for example in the daily clinical routine the data filing function of the critical pathway is useful when inquiring about cases of some critical pathway adopted during that year.
Using a programming function of Microsoft Excel, we developed a method, which easily files data such as patient ID, patient name and medical staff. For the critical pathway for chemotherapy with carboplatin and irinotecan as a prototype, we created an all-in-one type critical pathway system incorporating information such as the informed consent document and a graphical schema indicating individual chemotherapeutic adverse events.
Only the first page of the worksheet is accessed for input of clinical information. On the right side of this same worksheet, various links are arranged for viewing, printing and filing the data. The number of cases using this pathway can be seen at one glance in the filing section.
By using this critical pathway system, we established a comprehensive patient support system from admission through discharge of a patient.

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The Nasogastric feeding tube is widely used as an initial enteral feeding solution, but when wrongly inserted into the respiratory tract and feeding initiated, serious complications will happen such as pneumonia, empyema and pleural effusion. However, procedures to confirm the position of the feeding tube have not yet been established to prevent such complications.
The National Hospital Organization (NHO) Headquarters Kyushu Office has held two educational meetings, a follow-up survey and discussions with representatives of NHO Kyushu area hospitals and outlined the following recommendations:
1. The placement of newly inserted tubes should always be confirmed by x-ray.
2. When re-inserting the tube, a verification of a below 5.5 pH value of the feeding tube's aspirate or a re-confirmation of the tube's position by x-ray is essential.
3. Before every feeding, an observation of the mouth and a check of the external length of the tube from the nose should determine if the tube is partially removed or if coiling happens inside the mouth. Only after these verifications should healthcare workers start the feeding.

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Although the necessity of support for caregivers who are involved in medical accidents has been stressed in the past, a structured support system regarding procedures and manuals has not yet been well documented. The National Hospital Organization Headquarters Kyushu Office therefore drew up a manual, which helps the hospital to systematically support such staff. This manual introduced the following:
1) When a serious accident happens, the administrative executives, such as the president, vice president or nurse director, actively support the staff on the spot, appraising the staff regarding the appropriate conduct.
2) Initial communication with the involved family is to be done by the attending physician, head nurse and/or executives of the hospital. Nurses and inexperienced physicians who might have been involved in the accident will not participate in this first session.
3) No judgment is to be made before the final outcome of the review of the incident by the investigating peer review committee.
4) The peer review committee meeting is to be held with the participation of the involved caregivers, but should only strictly review the incident without blaming anyone involved.
5) If a caregiver's malpractice is proven, the hospital management should initiate communication to avoid a reoccurrence of this kind of incident.
Twelve educational meetings were conducted at the hospital to inform and educate the hospital staff about these new measures. Afterwards staff expressed trust in the hospital's administration as well as in the National Hospital Organization Headquarters Kyushu Office. Further studies will be performed to investigate if this manual actually contributes to a decrease of the number of caregivers quitting their positions.

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In October 2006 the Health Insurance Hitoyoshi General Hospital introduced a cancer registration support system using FileMaker Pro, which operates through an in-house LAN system. The functions of this system are “case finding”, “registration”, “input”, “prognosis investigation” and “regional prefecture-wide cancer registration”. Any staff member who has access authority can register cancer cases anytime. To facilitate early registration a “temporary registration” function was added to the system, which only needs the input of the patient's ID, name of attending physician and registration date.
Essential items are marked prominently, and furthermore contents and explanations are shown on the display for easy manipulation by the user. In addition, the data are submitted to the Kumamoto prefecture regional cancer registration and available for convalescence investigation.
With basic knowledge of FileMaker Pro this system is useful for any small or medium sized hospital for the introduction of a cancer registration system. It is also easily customized according to hospitals' needs.
Because this system permits the free input of the disease's name, it is especially suitable for hospitals which don't encode disease names completely and which still work without a computer or network system.

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