The local healthcare network is aimed at providing medical service higher in quality than that given at one hospital by diversifying the hospital function and making use of the local medical service resources efficiently.The critical path for local healthcare network is very useful tool to improve the quality and efficiency of the liaison medical treatment
Building up of a diseasewise local medical treatment network and IT operation of the liaison path are necessary to share information and analyze variance by using the liaison critical path.
The critical path for healthcare network management developed and used by the Hip Fracture Seamless Care Study Society in Kumamoto City has resolved these problems, suggesting the way the liaison path should be in the future.

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Clinical results in the surgical treatment of the femoral neck fracture have been well-established. In our hospital, these patients have spent about six weeks from admission until discharge. From October, 2003, we introduced a new critical path for the surgical treatment of the femoral neck fracture in order to efficiently shorten the hospital stay. However, a prolonged hospital stay more than three weeks was observed in some cases even after the introduction of the critical path. The purpose of this study is to investigate the risk factors which cause long hospital stay. We found that elderly patients over 85 years old, patients with urgent complication, delayed wheelchair transfer after surgery, are the risk factors that prolong hospital stay. Another critical path is required to the patient with these risk factors. Early transfer to the wheelchair after surgery is encouraged.

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Hip fracture is prevalent among elderly people, and it is more complicated in that group than in younger people because elderly people are more likely to have plural general comorbidities and have reduced physical function due to osteoporosis. Many studies have compared the progress of rehabilitation and length of hospital stay before and after introducing the use of critical pathways for hip fracture patients, but there are no clear criteria for the type of patients who qualify for the critical pathway, and the standards for qualification are different among clinicians. There are few studies about these criteria. This study was performed to explore the criteria and ratio of patients who stopped using critical pathways and to compare complications and patients' outcome between those who used critical pathways and those who did not. Data were collected from three hospitals that had introduced critical pathways in the care of hip fractures in Japan.
Although no comorbidities were significantly related to whether critical pathways were used or not, dementia was shown to be the most common reason for not using critical pathways. Dementia and delirium were significantly related to stopping the use of critical pathways. The possibility that patients with dementia stopped using critical pathways was high, and the outcomes of patients with dementia were difficult to assess;therefore, it is reasonable to assume dementia to be one of the reasons for not using critical pathways. In addition, it is necessary to consider the special critical pathways needed for people who have dementia, instead of not using critical pathways with them at all.

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In June 2003, we assessed work volume of a one-pharmacist pharmacy by means of the work sampling method, and the content of the work performed by the pharmacist in each time period was then analyzed. A questionnaire survey of patients was conducted in July 2004, and the degree of satisfaction in each time period was analyzed. Results of the work volume measurement revealed that the bulk of prescriptions were concentrated in the morning hours, when the amount of discretionary time on the part of the pharmacist was extremely limited. Results also showed that the degree of patient satisfaction was low during this busy morning period. This drop in perceived level of service should be preventable by means of an improvement in ratings of waiting time and patient compliance instruction, which have been linked to patients' degree of satisfaction with pharmacy use. However, because it is difficult to reduce dispensing time when only one pharmacist in on duty, improvement of patient perception of service level will entail taking steps to improve the environment so as to mitigate the psychological distress of waiting.

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The purpose of this study is to demonstrate the association between job satisfaction and management style in hospitals. The characteristic of management style contains five factors: management policy, work environment /job satisfaction, organizational management, personnel evaluation and training, and functional aggressiveness. Organizational management is the most influential factor in work environment/job satisfaction. Furthermore, organizational management is closely correlated with management policy.
Organizational management incorporates the following elements: leadership, relation between the supervisor and subordinate, and the setting of work objectives. Management policy includes these elements: the leaders' demonstration of organizational policy and ability to build concord between staff and management, and performance of each function based on management policy.
The results demonstrated that specific management style, specifically the leader's effort to clarify management policy, or his ability to support employees by helping them to understand management policy and to set their own job objectives, is vital in improving the job satisfaction of employees.

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There is evidence that silver alloy catheters reduce the incidence of catheter-associated urinary tract infection (UTI). However, silver alloy catheters are more expensive compared to standard urinary catheters. We assessed the economic impact of using silver alloy catheters by conducting simulation based on clinical decision analysis. We chose the cases requiring indwelling catheters within 1 week and estimated expected cost. We made a decision tree and conducted a simulation integrating the data of patient characteristics, clinical outcome, the probability of disease state progression and cost. Use of silver alloy catheters resulted in estimated cost saving of approximately 20% compared with standard catheters (5, 464 yen vs. 6, 777yen). Using silver alloy catheters for patients requiring short term urinary catheterization prevent the incidence of UTI and the prolonged length of hospital stay, and produce cost saving compared with standard catheters.

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Women's Outpatient Clinic was established in Chiba Prefectural Hospital in September, 2001. The diagnosis includes diseases in various fields such as menopausal symptoms, psychiatric disease, and gynecological disease. Some cases have serious problems such as domestic violence and traumatic distress in early years. Psychological approach was needed to resolve the problems of patients. Therefore, counseling program by clinical psychologist was started in February, 2002.
To evaluate the effect of counseling in Women's Outpatient Clinic, we analyzed factors such as chief complaint, symptoms, diagnosis, and clinical course of 23 patients, who take psychological therapy from February, 2002 to December, 2004. We also send out questionnaires to patients, doctors, and psychologist to pick up the effectiveness and problems of each place.
The diagnosis of patients included psychiatric diseases such as depression, menopausal depression, psychosomatic diseases, personal disorders, chronic pain, etc. All clients were satisfied with the psychological therapy. They felt therapist listened to and understood them. They also evaluated the psychological therapy because therapy made the chance to understand themselves objectively. Doctors evaluated the psychotherapy was effective in 75% cases, and all doctors expected the psychotherapy to be continued. The psychotherapist pointed out the needs for the co-operation with other clinical staffs (including physicians).
We found the psychological therapy was most effective in the women's outpatient clinic.

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We built a supply processing and distribution system (SPD) for drugs that was composed of an order entry system that could manage the amount of medicines prescribed. This system ordered by itself, and we could manage the cycle of this operation. Furthermore, this system was analyzed the automatic order program which was applied operations research (OR) as a system of drug inventory management at industrial technology. As a result, we could know immediately the amount of drug being prescribed and purchases because of this system's method of management data retrieval.We could reduce the stocks 37%, the total sum of the stocks 39% and the total sum of the stock at the dispensary 25% for half a year. It means this system contributes to the hospital's management.

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The critical path as a work schedule in the general industrial world is introduced into the medical world, and the usefulness came to be esteemed as a communication tool of between a medical worker and a patient and between medical workers. It surely has many potential benefits, but doesn't work effectively in some instances because a present pathway is not flexible to diversity of change of patients' conditions. In order to solve this problem, we developed an electronic critical path system using commercial database software called FileMaker Pro. In this paper, we report the mounting experiment of a new critical path which respond to change of patients' conditions.
Patient Condition Adaptive Path System (PCAPS) is made to respond to change of patients' conditions. In this system, a hospitalization process is divided into some processes and so-called unit pathway is created for every process, and we can go to the final goal (discharge), shifting between the units prepared beforehand according to change of a patients' conditions. We are tackling the electronization of PCAPS as research which received the research grant of the Ministry of Health, Labour and Welfare.
Actual employment was performed in the pediatrics ward of Shinko Kakogawa hospital which is also one of the research cooperation hospitals of this research group.

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In the convalescent ward of our hospital, critical pathways have been utilized; overview critical pathway covering the plan of whole period of hospitalization (long-term pathway). Nevertheless, we had troubles raised by the difference of discharge process between patient's family and medical staffs, and had problems due to insufficiency of support system for the life care after discharging. As the result, the period of hospitalization was inclined to be longer. To overcome these problems, we introduced “Careconference for discharge plan” into the long-term critical pathway. As a result, the average of period of hospitalization was shortened according to increase the number of discharge. We found it was much useful on the control of discharging chronic disease patients to systemize the approach by the team of many kind of field staffs.

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The guideline for physical restraint constituted by indications and principles of that was made on the basis of patient's human rights and safety in Kagawa Rosai Hospital in October, 2002. The document for informed consent of methods and complications of physical restraint were also made. Presence of too long physical restraint has been pointed out in using these guidelines and document, and necessity of process for relief of restraint was also indicated for more proper restraint. It became able to plan the standardization of restraint cancellation, but it seems to be difficult to decide restraint cancellation positively for nurse in considering the safety of patients. Further participation of doctors in this field is required.

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The records about cleaning and sterilization of used endoscopes have been left in our hospital since 2003. At first, the records were written on paper. However, the system often caused defectiveness of records, and required a long time for check of the records. Then, on the occasion of introduction of ordering-entry system in 2004, the records about cleaning and sterilization of endoscopes including endoscope number, name of patients, concentration of disinfectant and name of responsible person, were computerized using our originally developed management software. As a result, the records could be left easily and surely, leading to guarantee of sterilization of used endoscopes.

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Traditional Failure mode and effect analysis (FMEA) that has been successfully used in industry for many decades, and is a specific methodology to evaluate a system, process in which failures can occur and can be used to improve several types of processes or subprocesses. In FMEA, each failures are evaluated their occurrence, severity and detection. However, in case of using medical failures, Healthcare failure modes and effect analysis (HFMEA) is conceptually easier to apply because of its definitions and algorithms.
HFMEA has been developed by Veterans Affairs National Center of Patient Safety specifically for Healthcare and a prospective assessment that identifies and improves steps in a process, thereby reasonably ensuring a safe and clinically desirable outcome. HFMEA is a 5 step process that uses a team to proactively evaluate a medical process. The steps are as follows: Step 1: Define the HFMEA topic, Step 2: Assemble the team, Step 3: Graphically describe the process, Step 4: Conduct a hazard analysis, Step 5: Actions and outcome Measures. HFMEA is thought to be a very useful tool in healthcare specific analysis of proactive risk assessment.

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