The purpose of the critical path is outcome management of medical service. Most important item of the critical path format is outcome, especially, criteria for discharge and length of hospital stay. The other items are set to achieve dally outcomes. The outcome must be measurable contents. Improvement of the critical path is done by evidence based medicine and analysis of valiance. The critical path connected with health care institute of local distinct is necessary for medical service relay.

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Education of pathology to the medical student is composed of the lecture and the practice. The medical student has the problem that it is difficult to study general pathology excluding the practice room. In addition, there was a problem that the microscopic specimen was deteriorated at time. So that, the teacher of department of pathology has spared large time to making the specimen and the manual every year. To solve such a problem, we worked on making of an electronic image of the pathological organization and developed the teaching material of the general pathology for the personal computer. CD-ROM of the developed material for general pathology was distributed to the third grade medical students. After the lecture, the practice, and the examination of the General Pathology, the questionnaire survey was done to all students.
In this thesis, we describe the outline of the teaching material and the questionnaire survey result of the developed general pathology.

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We made a guideline for the purpose of minimum physical restraint in the acute care ward. This guide line was based on the principle of physical restraint and fulfilling the criteria for that, considered from literature. And we used the adequately illustrated manual of physical restraint for explanation to the patient and the family. After that, we got the agreement subscribed by the patient or the family. In this paper, we reported the analysis of the data using this system in three months. Also, we reported the measures against falling without physical restraint in our care ward.

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[Objective] In April 2002, restrictions on the prescription term that can be dispensed to outpatients were in principle abolished. This study analyzed conditions under which outpatients obtain their medications in order to determine what factors should be kept in mind when prescribing long term supply of medication at one time.
[Methods] Questionnaires were distributed to outpatients visiting 19 stores belonging to a pharmacy chain in the Kansai and Hokuriku regions during a one-week period in mid-May 2002. Responses from outpatients who have chronic diseases were used for the analysis.
[Results& Discussion] Of the 1, 745 questionnaire distributed, 1, 226 were returned. Among these, responses from the 696 respondents were used for the analysis. The majority of patients (85.3%) had been receiving treatment for a year or more, and 9.8% of them had obtained an increase in duration of medication supply per prescription since April 2002. The results of linear regression analysis revealed that the factors having some bearing on patients' desire to “pick up medications without having to see the doctor first” included age of respondent, frequency of visits to hospital to pick up medications or prescriptions, desired duration of medication supply at one time, and compliance with prescription regimen. Results also suggest that patient compliance is influenced by the occupation of respondent, certain specific diseases, the length of time for which the patient has been receiving regular outpatient treatment, and his/her preferences regarding how the medications are to be picked up.
[Conclusion] These findings indicate that increasing the duration of medication supply at one time purely in response to the demands of patients risks deterioration in the quality of drug therapy.

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Root Cause Analysis (RCA) or the SHEL Model are thought to be effective techniques most commonly used after something bad has occurred in order to identify underlying causes. We compared the two methods by using the same adverse events. RCA is labor-intensive and takes time, however, is much easier to pinpoint problems and establish priority of measures than SHEL Model.

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‹Purpose› Disabilities suffered after surgical treatment should be well-informed to the patients and their families. To the better support for these disabilities, the Treatment Process Scenario (TPS) was developed and its efficiency was discussed.
‹Objects and methods› By references and brainstorming, the disabilities of patients suffered after total laryngectomy are arranged, beginning from the appearance of the symptoms, to the operation, and continuing for years after discharge from hospital. Using this TPS, inpatients and outpatients are interviewed to review the contents and outcomes are evaluated.
‹Results› From the interviews, followings were found.(1) The TPS mostly covers the disabilities suffered after surgical treatment.(2) The main disabilities listed by inpatients were “loss of voice” and “change in diet” and by outpatients, “the communication difficulty.” (3) Some critical points were discovered during the treatment process in which care support would be most effective or necessary.

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Most hip fracture patients are old, which necessitates early interventions to regain their ability to walk and to prevent them from bed-ridden condition. In this study we compared differences in patients' length of hospital stays and the timing of postoperative rehabilitation before and after the introduction of critical pathways at three hospitals, A, B, and C. After the introduction of critical pathways at hospital A, the average length of hospital stay was shortened without decreasing patients' ambulatory ability at discharge. The average length of stay at hospital B was shorter than other hospitals before the introduction of critical pathway; the first physical therapists' visit to patients' bedsides was standardized more after the introduction of critical pathway. Although patients' ability at discharge decreased after the introduction of critical pathway at hospital C, its rehabilitation program standardized; average length of hospital stay shortened; and patients' ambulatory ability recovered faster. Each hospital, A, B, and C achieved its expected outcomes or goals according to the aims of introducing critical pathways.

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We report postoperative rehabilitation program without cervical orthosis for cervical laminoplasty. By reviewing the outcome (criteria for discharge, the length of hospital stay) we could make the postoperative rehabilitation program earlier than before. At first the length of hospital stay was set at 4 weeks. After reviewing with the path, it was changed 2 weeks at last. The average time to start the sitting position, standing position and walking alone was 3.3±2.7 days, 4.3±2.7 days, 7.0±8.1 days with 4-weeks path, 1.2±0.4 days, 2.2±1.0 days, 4.1±2.3 days with 3-weeks path and 1.0±0.0 day, 1.6±1.7 days, 3.1±3.0 days with 2-weeks. Guidance and explanation on the training before operation made the postoperative training smooth. When we start ambulation immediately after surgery without cervical orthosis, we must pay attention to the motion of getting up. In the variance examination, there was no negative variance in the case of patients who walk early after surgery. The rate of hospital change was about 40% in each path. For the cases under consideration for postoperative hospital change, effects are being made to share information by using the exclusive path which was jointly developed by our hospital and the hospital to which we introduce patients. The critical path is a useful tool to manage the outcome of medical treatment.

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We studied the significance of teaching bed-side cardiologic examination skills using “Ichiro”, the new cardiology patient simulator developed by Takashina. The subjects were 75 third-year nursing college students. Examination skills were evaluated by a test before and after the 90 minutes lesson using “Ichiro”. These were marked out of 30, which consisted of 15 points for inspection and palpation, and 15 points for auscultation.
Scores for the inspection and palpation test were 10.8±1.9 points before the lesson and 13.3±1.2 points after the lesson, and scores for the auscultation were 11.3±3.4 and 12.7±2.8 points, respectively. Accordingly, the total scores were 22.1±4.1 points before the lesson and 26.0±3.4 points after the lesson. It is confirmed that scores after the lesson were significantly better than those before the lesson. Furthermore, the degree of improvement in the test regarding inspection and palpation was significantly better than that of auscultation. In addition, there were significant correlation between the scores before the lesson and after the lesson.
In the past, the education on physical assessment was mainly dependent upon OJT (on the job training), however, it is suggested that it can be done at basic nursing skills education. Furthermore, it is conceived that the level and ability of the students should be taken into account to teach cardiological examination skills effectively using “Ichiro”

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Nursing care for patients of a chronic period in the recuperation ward is different from that of an acute period, in respect that i) it takes longer time to get the outcome of caring on the patients, ii) not only nurses but also care workers participate in caring, and that iii) assistance for activities of daily living is the main business for nurses and care workers. Considering such differences, we have designed a critical path specifying the nursing care in the recuperation ward and analyzed its usefulness.
Critical path consisted of two parts; i) The over-view-path specifying the long plan from admission to discharge and ii) the all-in-one-path including nursing record, vital signs, doctor's instructions, and treatment. In the latter path, the short (weekly or daily) plan correlating the long plan was clearly stated. Furthermore, in order to shorten the time for recording at the desk and to share the information among nurses and care workers, traditional record in SOAP-style was not used but checking lists of the points correlating the care plan were adopted. In nine patients of disuse syndrome caused by cerebral vascular disease in the recuperation ward of YMC (male=4, female=5, 77.3±4.7 y.o.), the acquirement of the abilities relating daily living was analyzed a month after the introduction of critical path. Significant improvement was detected in oral eating, neck contracture, and spontaneous speaking, with no effect on abilities of excreting and transfer.
This critical path had effect on recover of the abilities relating daily living in patients, as well as it shortened the time of recording at the desk for nurses and care workers.

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Our vice head nurse group on National Douhoku Hospital studied the results of the annual surveys of the patients satisfaction, from1999. The results showed there were the low scores about explanations and teaching to patients. Thirty-two. eight percent of patients were dissatisfied with their explanations on last year examination, especially.
In the time to come, we will become an independent administrative agency from national hospital system. It is necessary to improve the patient's satisfaction for the benefit to the shortness of the hospital stay, to maintain the number of patients and their satisfaction.
Therefore, on this research, we examined the availability of the discharge guidelines to patients and nurses at the same time. As a result of these studies, more than 90 percent of the patients and nurses recognized the need for the discharge guidelines. However, from the records of the answer, only 61.4% patients received the discharge guidelines and 68.4% nurses teaching thought that the discharge guidelines were insufficient. Moreover, there were several differences of importance of the contents of the discharge guidelines between those recognized by the patients and nurses.
Form these results;there were some reasons why nurses could not teach the discharge guidelines to patients sufficiently. As can be seen, we indicated the points needing improvement to the discharge guidelines to enhance the patient's satisfaction

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Among our 5336 incident/accident reports in our hospital from Apr. 2002 to Mar. 2003, 614 cases were reported on accidental falls with 26 cases (4%) at higher than Level 3. This number is about 1/4 of all accident reports in higher than Level 3 injury.
The accidental fall occurred mostly from midnight to morning, where the elderly over 80 years of age tended to have accident with higher than Level 3. The most common place was sickrooms (64%), although the incidence varied among wards in the rate of occurrence. We now have developed a simple surveillance equipment for getting out of bed interlocked with the nurse call system and have applied to 28 patients in 10 different wards. We concluded that the surveillance equipment was effective in preventing accident falls from the hospital bed by half. Among 10 wards provided with our prevention equipment, 7 wards were reported to be effective for preventing accidental falls, and 6 wards requested for continual use of our surveillance equipment even after the trial.
We are now looking forward to commercialization of our surveillance equipment for preventing accidental falls from the hospital bed.

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The critical path has many benefits in the medical institute, and most of the hospitals in the whole country use the path. But it is difficult that one disease apply to one path, because even with the same disease each patient has its own personality and variations. And there are so often variances and deviations that critical pathes are seldom continued and completed.
In order to solve these problems, we developed the personal computer (PC) assisted critical path “Crippa-kun II ” that accepts the variety and variances in the patient. This system consists of two parts, [Master] and [Critical path]. The part of [Master] works to set up [Critical path] conditions (patient's personality, outcomes, initial conditions). [Critical path] contains the critical path sheet for each patient and the usually used as the medical records, and to be used every day. The most pronounced characteristic of “Crippa-kun II” is that the status of outcomes achieved in each day is affected in the program for the next day. For example, when the outcomes of one day are over and the critical path is checked, the critical path and outcomes of the following day appear on the PC display.
The result of “Crippa-kun II” is good enough and most of the patients continued the use of their critical pathuntil their discharge. It has been also often observed that “Crippa-kun II” increases the motivation of the patients through its outcome-managed programming.

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Nerve blocks are conducted mainly for the patients who suffer from pain in our pain clinic. There are varieties of complications of nerve blocks, including local anesthetic intoxication, hemorrhage, hypotension, nerve palsy and etc. Therefore we inducted critical path into pain clinic. We report that critical path is very useful for the patients', medical and comedical staffs to get more profound comprehension for nerve blocks, early diagnosis of complications, improving team medicine, costs management, service efficiency, making a solid informed consent. In our department, we induce critical path into celiac plexus block, thoracic/lumbar parasympathetic block, nerve root block, Gasserian-ganglion-block for nerve blocks and facial palsy for disease.

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As a part of the medical safety management system, the efforts to establish the incident report system and the hospital organization control system have been made in every medical institution.However such efforts are not enough. However, safety control mechanism will never work properly if the efforts would be made only by limited number of people. This work requires a system in which all the staff members should be involved. Regardless of line of work, each one of the hospital staffs should be aware that it is his or her duty to secure the quality and safety of medical treatment. For that purpose, it is important to have safety culture fostered across the organization. The Ministry of Health, Labor and Welfare defines the medical treatment safety culture as “A way of thinking or an attitude that all the staffs engaged in the medical services give the highest priority to patient's safety, and strive for its realization and also the way organizations toward the goal.” It is not easy to foster the safety culture, however, while making laborious efforts toward it, we have found the following five points to be effective.(1) Declaration to launch organization wide efforts to seriously tackle the “medical treatment safety” issue.(2) Activities of the project teams that attempt to solve the problems existing in multiple lines of work (3) Issuance of a self-adhesive labels to those having attended the training lectures concerning the medical treatment safety.(4) Provision of concrete feedbacks that seem to have contributed to improvement.(5) Study meeting over the idea of Quality Control (QC) based-problem solving method. Fostering the safety culture is not something to be achieved at one time in the future, but rather it should be the whole continuing process that needs to be tackled with concrete measures and all out organizational efforts.

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The medicine brought in by the patient at the time of hospitalization is increasing in types and quantities. On the other hand, due to lack of information there was no common consensus concerning the medicine brought in by the patient, thus each medical department had managed differently on their own decisions. For unified agreements on the medicine brought in by the patient, our medical safety management office had organized a management committee by doctors, nurses, and pharmacists and reviewed the current status on the medicine brought in by the patients for medical risk management by questionaires distributed to risk managers of doctors, nurses and pharmacists. Based on the results, we were able to summarize “formulation of guidelines for handling medicines brought in by the patients at the time of hospitalization” and created “a manual for handling medicines brought in by the patients”, and acknowledged to all medical personnel in our hospital.

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We theorized that branding of general hospitals might be similar to that in the manufacturing and service in dustries.
We investigated the branding of general hospitals both by reviewing branding in daily medical practice and with reference to corporate and industrial publications. Primarily, two articles were used as reference materials. The first was “Context Branding” by Akutsu and Ishida about branding tactics and the other was “Driving Brand Value” by Duncan and Moriarty.
In this study, we found that the quality of health service is the local brand and the persons who could promote the hospital were not only patients but also the local residents and hospital employees. We found that we could build up the health service brand when the aims of the hospital were made into clear policies, so that the services provided and the image could be combined by communication between the hospital and residents. These points about the branding of health services are virtually the same as in other industries.

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