How can we improve the quality of health care in Japan?

How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative study

BACKGROUND

Patient incident reporting systems have been widely used for ensuring safety and improving quality in care settings in many countries. However, little is known about the way in which incident data are used by frontline clinical staff. Furthermore, while the use of a systems perspective has been reported as an effective way of learning from incident data in a multidisciplinary team, the level of adaptability of this perspective to a different cultural context has not been widely explored. The primary aim of the study, therefore, was to investigate how healthcare practitioners in Japan perceive the reporting systems and utilize a systems perspective in learning from incident data in acute care and mental health settings.

METHODS

A non-experimental, descriptive and exploratory research design was adopted with the following two data-collection methods: 1) Sixty-one semi-structured interviews with frontline staff in two hospitals; and 2) Non-participatory observations of thirty-seven regular incident review meetings. The two hospitals in the Greater Tokyo area which were invited to take part were: 1) a not-for-profit, privately-run, acute care hospital with approximately 500 beds; and 2) a publicly-run mental health hospital with 200 beds.

RESULTS

While the majority of staff acknowledge the positive impacts of the reporting systems on safety, the observation data found that little consideration was given to systems aspects during formal meetings. The meetings were primarily a place for the exchange of practical information, as opposed to in-depth discussions regarding causes of incidents and corrective measures. Learning from incident data was influenced by four factors: professional boundaries; dealing with a psychological burden; leadership and educational approach; and compatibility of patient safety with patient-centered care.

CONCLUSIONS

Healthcare organizations are highly complex, comprising of many professional boundaries and risk perceptions, and various communication styles. In order to establish an optimum method of individual and organizational learning and effective safety management, a fine balance has to be struck between respect for professional expertise in a local team and centralized safety oversight with a strong focus on systems. Further research needs to examine culturally-sensitive organizational and professional dynamics, including leader-follower relationships and the impact of resource constraints.

The impact of hospital accreditation on the quality of healthcare: a systematic literature review

BACKGROUND

Accreditation is viewed as a reputable tool to evaluate and enhance the quality of health care. However, its effect on performance and outcomes remains unclear. This review aimed to identify and analyze the evidence on the impact of hospital accreditation.

METHODS

We systematically searched electronic databases (PubMed, CINAHL, PsycINFO, EMBASE, MEDLINE (OvidSP), CDSR, CENTRAL, ScienceDirect, SSCI, RSCI, SciELO, and KCI) and other sources using relevant subject headings. We included peer-reviewed quantitative studies published over the last two decades, irrespective of its design or language. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers independently screened initially identified articles, reviewed the full-text of potentially relevant studies, extracted necessary data, and assessed the methodological quality of the included studies using a validated tool. The accreditation effects were synthesized and categorized thematically into six impact themes.

RESULTS

We screened a total of 17,830 studies, of which 76 empirical studies that examined the impact of accreditation met our inclusion criteria. These studies were methodologically heterogeneous. Apart from the effect of accreditation on healthcare workers and particularly on job stress, our results indicate a consistent positive effect of hospital accreditation on safety culture, process-related performance measures, efficiency, and the patient length of stay, whereas employee satisfaction, patient satisfaction and experience, and 30-day hospital readmission rate were found to be unrelated to accreditation. Paradoxical results regarding the impact of accreditation on mortality rate and healthcare-associated infections hampered drawing firm conclusions on these outcome measures.

CONCLUSION

There is reasonable evidence to support the notion that compliance with accreditation standards has multiple plausible benefits in improving the performance in the hospital setting. Despite inconclusive evidence on causality, introducing hospital accreditation schemes stimulates performance improvement and patient safety. Efforts to incentivize and modernize accreditation are recommended to move towards institutionalization and sustaining the performance gains. PROSPERO registration number CRD42020167863.

Patient Safety Activity Under the Social Insurance Medical Fee Schedule in Japan: An Overview of the 2010 Nationwide Survey

OBJECTIVES

Little is known about patient safety performance under the social insurance medical fee schedule in Japan. The Health Ministry in Japan introduced the preferential patient safety countermeasure fee (PPSCF) to promote patient safety in 2006 and revised the PPSCF system in 2010. This study aims to address the patient safety performance status at hospitals implementing the PPSCF.

METHODS

A nationwide questionnaire survey targeting 2674 hospitals with the PPSCF was performed in 2010 to 2011. The 627 participant hospitals were divided into the following three groups: 178 hospitals implementing PPSCF 1 with 400 beds or more (group A), 286 hospitals implementing PPSCF 1 with 399 beds or fewer (group B), and 163 hospitals implementing PPSCF 2 (group C).

RESULTS

The mean numbers (standard errors) of patient safety managers were 1.45 (0.07) in group A, 1.12 (0.04) in group B, and 0.37 (0.12) in group C (P < 0.001). The participation number and rates of all staff for the patient safety seminar were 1721 (167) and 1.64 (0.10) in group A, 580 (26) and 1.94 (0.09) in group B, and 349 (31) and 1.98 (0.17) in group C (P < 0.001, P = 0.105).These results can be explained because hospitals with PPSCF 1 (groups A and B) must assign at least one full-time patient safety manager, whereas hospitals with PPSCF 2 (group C) are not required to do so. Patient safety performance at hospitals with PPSCF 1 was more active than that at hospitals with PPSCF 2. However, when the values were converted to per capita or per 100 beds, there were no differences across the three groups.

CONCLUSIONS

The PPSCF encourages hospitals to perform actions for patient safety by providing incentives under the social insurance medical fee schedule in Japan.

Changes in the quality of diabetes care in Japan between 2007 and 2015: A repeated cross-sectional study using claims data

AIM

To assess the temporal changes in the quality indicators pertaining to the process measures of diabetes care during a recent decade in Japan.

METHODS

A five-fold repeated cross-sectional study was conducted using health insurance claims data provided by the Japan Medical Data Center between April 2006 and March 2016. We identified 46,631 outpatients with antidiabetic medication who regularly visited hospitals or clinics at least every three months. We evaluated the quality indicators pertaining to glycemic control monitoring, lipid profile monitoring, retinopathy screening, nephropathy screening, and appropriate medication choice. The proportions of patients who received appropriate examinations/prescriptions, by observation period and either the type of antidiabetic medication or facility type were estimated using generalized estimating equation (GEE) models with multiple covariate adjustments.

RESULTS

The quality indicator values for appropriate medication choice and nephropathy screening improved between 2007 and 2015, whereas those for glycemic control monitoring and retinopathy screening remained suboptimal. Patients prescribed medications in larger hospitals were likelier to undergo the recommended examinations (e.g. retinopathy screening: 36.1% (95% CI: 35.4-36.7%) for clinic, 40.6% (95% CI: 39.1-42.2%) for smaller hospital, and 46.0% (95% CI: 44.8-47.2%) for larger hospital in 2015).

CONCLUSIONS

Several process measures of diabetes care remained suboptimal in Japan.

Accreditation effects on health service quality: nurse viewpoints

PURPOSE

The purpose of this paper is to determine accreditation effects on Iranian military hospital health service quality through nurses' viewpoints.

DESIGN/METHODOLOGY/APPROACH

The paper is a cross-sectional questionnaire-based study. Sampling drew from a hospital nurse census ( n=160). Descriptive statistics were used to analyze participant demographics and nurses' views. Linear regression analysis determined the independent variables' overall effect on the accreditation quality results dimension (dependent variable).

FINDINGS

From the nurses' viewpoints, accreditation effects on services quality mean score was 3.60±0.61. Linear regression analysis showed that leadership and quality management were identified as the most important accreditation quality predictors. The R² value (0.698) showed that nearly 70 percent of the dependent variable changes were affected by the independent variables.

PRACTICAL IMPLICATIONS

This study gives hospital managers a deeper insight into accreditation and its effects on military hospital service quality. Military hospitals benefit from military organization such as hierarchy and command chain, so managers should employ these characteristics to adopt appropriate policies to promote human resource management as a competitive advantage. Furthermore, results will guide public and private hospital managers on how to manage organizational variables that benefit from accreditation.

ORIGINALITY/VALUE

Accreditation was introduced as a hospital quality improvement program. However, implementing accreditation programs should be cost-effective. Hospital managers and employees should feel that accreditation can improve service quality. Nurses had positive viewpoints about accreditation and its effects on military hospital service quality.

Accreditation in one teaching hospital: a phenomenology study among Iranian nurses

PURPOSE

Accreditation helps to ensure safe and high-quality services in hospitals. Different occupational groups have various hospital accreditation experiences. The purpose of this paper is to investigate nurses' accreditation experience and its effects on Iranian teaching hospital service quality.

DESIGN/METHODOLOGY/APPROACH

This was a qualitative study involving a phenomenological approach to studying nurses' hospital accreditation experience and understanding the effects on Iranian teaching hospital service quality. Data were collected using two focus groups in which nurses were selected using purposive sampling. Transcripts were analyzed using content analysis.

FINDINGS

Nurses' experiences showed that hospital administrators and nurses had greater role in implementing accreditation than other occupational groups. Accreditation improved patient-centeredness, patient safety, logistics and managerial processes and decision making. However, a weak incentive system, extra documentation and work stress were negative experiences.

PRACTICAL IMPLICATIONS

Nurse experience, as the most important care team member, reveals accreditation's strengths and weaknesses and its effects on service quality.

ORIGINALITY/VALUE

The author used a phenomenology approach to measure accreditation effects on service quality - a valuable tool for understanding a phenomenon among those that experience hospital accreditation processes.

Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports

OBJECTIVES

We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements.

DESIGN

Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination.

SETTING

A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue.

RESULTS

Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%).

CONCLUSIONS

Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.

Differential Effects of Declining Rates in a Per Diem Payment System

The paper demonstrates differential effects of a prospective payment system with declining per diem rates, dependent on the percentiles of length of stay. The analysis uses dynamic panel data estimates and a recent nationwide administrative database for major diagnostic categories in 1068 Japanese hospitals in 2006-2012 to show that average length of stay significantly increases for hospitals in percentiles 0-25 of the pre-reform length of stay and significantly decreases for hospitals in percentiles 51-100. The decline of the average length of stay is larger for hospitals in higher percentiles of the length of stay. Hospitals in percentiles 51-100 significantly increase their rate of nonemergency/unanticipated readmissions within 42 days after discharge. The decline in the length of total episode of treatment is smaller for hospitals in percentiles 0-25. The findings are robust in terms of the choice of a cohort of hospitals joining the reform. The paper discusses applicability of 'best practice' rate-setting to help improve the performance of hospitals in the lowest quartile of average length of stay. Copyright © 2015 John Wiley & Sons, Ltd.

Perceptions of nurses on the impact of accreditation on quality of care

Purpose

– This article aims to investigate perceptions of Turkish nurses on the impact of accreditation on quality of care and the effect of accreditation on quality results.

Design/methodology/approach

– This study was performed as a cross-sectional, questionnaire-based survey on 258 nurses who started working in the hospital before it was accredited and continued to work during and after accrediation and who therefore knew both the hospital's pre-accrediation and post-accreditation periods. In this study, descriptive statistical analyses (means and standard deviations) were carried out to explore the views of the participants on “quality results,” “benefits of accreditation” and “participation of employees.” “Quality results” was considered to be the dependent variable, while “benefits of accreditation” and “participation of employees” were accepted as the independent variables. The relationship between the dependent variable and the independent variables was tested using Pearson correlation and multiple regression analysis. External patient satisfaction data collected by the quality department of the hospital before and after accreditation were also investigated.

Findings

– It was found that nurses had generally high scores for the items concerning the benefits of accreditation. There was a statistically significant positive correlation between the dependent variable (quality results) and the independent variables (benefits of accreditation and participation of employees). Regression analysis indicated that R2=0.461 and the extent to which the independent variables explained the dependent variable was 46.1 per cent, which is a high rate. Patient satisfaction scores increased after accreditation.

Practical implications

– Our study suggest that providing support for nurses, especially nurses with administrative responsibilities and incorporating employees into the process are important for exercising quality standards.

Originality/value

– Hospital accreditation has a positive impact on quality results especially on quality of care provided to patients and patient satisfaction. Study findings could guide policy makers and hospital managers in Turkey and in other countries who are preparing or implementing accreditation.

Patient safety education at Japanese nursing schools: results of a nationwide survey

BACKGROUND

Patient safety education is becoming of worldwide interest and concern in the field of healthcare, particularly in the field of nursing. However, as elsewhere, little is known about the extent to which nursing schools have adopted patient safety education into their curricula. We conducted a nationwide survey to characterize patient safety education at nursing schools in Japan.

RESULTS

Response rate was 43% overall. Ninety percent of nursing schools have integrated the topic of patient safety education into their curricula. However, 30% reported devoting less than five hours to the topic. All schools use lecture based teaching methods while few used others, such as role playing. Topics related to medical error theory are widely taught, e.g. human factors and theories & models (Swiss Cheese Model, Heinrich's Law) while relatively few schools cover practical topics related to error analysis such as root cause analysis.

CONCLUSIONS

Most nursing schools in Japan cover the topic of patient safety, but the number of hours devoted is modest and teaching methods are suboptimal. Even so, national inclusion of patient safety education is a worthy, achievable goal.

Healthcare accreditation systems: further perspectives on performance measures

OBJECTIVE

The purpose of this paper is to identify and suggest a number of performance measures to facilitate the evaluation of accreditation programs in healthcare.

METHODS

The paper is based on an exploratory research which has used qualitative methods, including snowball sampling technique, email interview and thematic content analysis.

PARTICIPANTS

Respondents (experts and professionals) were selected from a diverse spectrum ranging from healthcare organizations, universities and accreditation-associated institutions.

RESULTS

The analysis of the data provided key measures to be considered in the evaluation of accreditation programs' impact at macro and micro levels as well as their nature and operations. The measures can be used to, for example, assess the degree of stakeholders' reliance on accreditation results, measure the cost of accreditation for participating organizations and serve as a formal mechanism for accredited organizations to appeal accreditation decisions.

CONCLUSIONS

This paper has brought together a number of generic, yet influential and workable, measures which could be utilized for assessing the overall performance of an accreditation program in healthcare. The application of these measures depends on the features of given accreditation program and the context in which the program operates. Therefore, the next step/steps in the assessment of an accreditation program might be choosing the measures suiting that program.

Cost containment and quality of care in Japan: is there a trade-off?

Japan's health indices such as life expectancy at birth are among the best in the world. However, at 8·5% the proportion of gross domestic product spent on health is 20th among Organisation for Economic Co-operation and Development countries in 2008 and half as much as that in the USA. Costs have been contained by the nationally uniform fee schedule, in which the global revision rate is set first and item-by-item revisions are then made. Although the structural and process dimensions of quality seem to be poor, the characteristics of the health-care system are primarily attributable to how physicians and hospitals have developed in the country, and not to the cost-containment policy. However, outcomes such as postsurgical mortality rates are as good as those reported for other developed countries. Japan's basic policy has been a combination of tight control of the conditions of payment, but a laissez-faire approach to how services are delivered; this combination has led to a scarcity of professional governance and accountability. In view of the structural problems facing the health-care system, the balance should be shifted towards increased freedom of payment conditions by simplification of reimbursement rules, but tightened control of service delivery by strengthening of regional health planning, both of which should be supported through public monitoring of providers' performance. Japan's experience of good health and low cost suggests that the priority in health policy should initially be improvement of access and prevention of impoverishment from health care, after which efficiency and quality of services should then be pursued.

Quality of care for diabetes patients using National Health Insurance claims data in Japan

BACKGROUND

Assessment of the quality of care is a key element in current diabetes care. However, the quality of care for diabetes patients in Japan has rarely been reported.

OBJECTIVES

To assess the quality of diabetes care in two communities in Japan by using National Health Insurance claims data.

METHODS

We analysed claim data of 13,650 beneficiaries of National Health Insurance in two communities in Japan from May 2006 to April 2007. Diabetes cases were identified by using a case detection algorism. Our main outcome measures were three process quality indicators: (1) haemoglobin A1c (HbA1c) testing; (2) annual eye examination; and (3) annual nephropathy screening, recommended in the existing clinical guidelines. We calculated the performance rate of each quality indicator and examined the effects of demographic characteristics and co-morbid conditions.

RESULTS

We identified 636 diabetes cases. Of these, 97.0% had at least one HbA1c test, and 69.8% had ≥ 4 tests during the study period. The odds ratios (ORs) for ≥ 4 HbA1c tests were lower in subgroups aged 75-79 (OR 0.58, 95% confidence interval 0.35-0.96), and aged ≥ 80 (OR 0.54, 95% confidence interval 0.32-0.88) compared with the subgroup aged <70 after adjusting for other patient characteristics. The annual rate for eye examinations and nephropathy screenings were 20.8% and 5.8% respectively.

CONCLUSIONS

We found high performance rates for HbA1c testing, while the annual rates for eye examinations and nephropathy screenings were suboptimal. Using administrative data would facilitate more comprehensive assessment of the quality of care in Japan.

Doctor as criminal: reporting of patient deaths to the police and criminal prosecution of healthcare providers in Japan

Background

In Japan, medical error leading to patient death is often handled through the criminal rather than civil justice system. However, the number of cases handled through the criminal system and how this has changed in recent years has not previously been described. Our aim was to determine the trend in reports of patient death to the police and the trend in the resulting prosecution of healthcare providers for medical error leading to patient death from 1998 to 2008.

Methods

We collected data regarding the number of police reports of patient death made by physicians, next-of-kin, and other sources between 1998 and 2008. We also collected data regarding the number of resulting criminal prosecutions of healthcare providers between 1998 and 2008. Reporting and prosecution trends were analyzed using annual linear regression models.

Results

Reports: The number physician reports of patient deaths to the police increased significantly during the study period (slope 18.68, R² = 0.78, P < 0.001) while reports made by next-of-kin and others did not. Mean annual reporting rates by group were physicians 130.1 (± 70.1), next-of-kin 29.3 (± 12.5), and others 10.4 (± 6.0). Prosecutions: The number of resulting criminal prosecutions increased significantly during the study period (slope 9.21, R² = 0.83, P < 0.001). The mean annual prosecution rate was 61.0 (± 33.6).

Conclusions

The reporting of patient deaths to the police by physicians increased significantly from 1998 to 2008 while those made by next-of-kin and others did not. The resulting criminal prosecutions of healthcare providers increased significantly during the same time period. The reasons for these increases are unclear and should be the focus of future research.

Developing 21st century accreditation standards for teaching hospitals: the Taiwan experience

BACKGROUND

The purpose of this study is to establish teaching hospital accreditation standards anew with the hope that Taiwan's teaching hospitals can live up to the expectations of our society and ensure quality teaching.

METHODS

The development process lasted two years, 2005-2006, and was separated into three stages. The first stage centered on leadership meetings and consensus building, the second on drafting the new standards with expert focus groups, and the third on a pilot study and subsequent revision.

RESULTS

Our new teaching hospital accreditation standards have six categories and 95 standards as follows: educational resources (20 items), teaching and training plans and outcomes (42 items), research and results (9 items), development of clinical faculty and continuing education (8 items), academic exchanges and community education (8 items), and administration (8 items).

CONCLUSIONS

The new standards have proven feasible and posed reasonable challenges in the pilot study. We hope the new standards will strengthen teaching and research, and improve the quality of hospital services at the same time.

Quality and performance improvement for mental healthcare in Japan

PURPOSE OF REVIEW

Until recently, assessing the quality of mental healthcare was a relatively new concept in Japan, although universal health coverage is provided. In this study, I describe the current developments in quality and performance improvement for mental healthcare in Japan.

RECENT FINDINGS

There is very little published literature on systematic quality improvement activities for mental healthcare in Japan. The mechanisms for improving the quality in mental healthcare are underpinned by legislation, government policies, professional standards, peer reviews, and consumer involvement. Although a national monitoring system is available in mental healthcare, quality improvement efforts focus primarily on structural issues. In accordance with the policy shift from institutions to community, this part of the healthcare is still in a phase of building up community care, and most of the efforts are directed toward the quantity rather than quality of care. New movements geared toward performance improvement are emerging in the form of reducing polypharmacy of antipsychotic prescriptions and minimizing seclusion and restraint.

SUMMARY

Assessing and improving quality and performance are gradually occurring in mental healthcare in Japan in response to the needs of society for high quality care.

Perspectives in medical education: 6 reflections on the state of clinical training for residents in Japan

The Muribushi Project in Okinawa, Japan, is breaking new ground for residency training in Japan by explicitly emphasizing clinical skills training and primary care. The core philosophy of the Project is defined by seven "concepts" that commit to (i) establishing cooperation between several hospitals to educate good clinicians; (ii) providing the best learning environment at multiple training sites; (iii) following global standards of practice; (iv) focusing on primary and emergency care of common diseases; (v) emphasizing faculty development through international exchange; (vi) providing residents with opportunities to obtain training abroad; and (vii) improving the quality of medical care through residents. Observations by the author during two week-long visits, one year apart, reveal that the Muribushi Project is fulfilling conceptual goals (iv), (v) and (vi) by emphasizing primary care and encouraging international exchange for faculty and students. The opportunity exists to fulfill goals (i) and (ii), but it is not being exploited because programs at member hospitals are not integrated, so that residents spend the duration of their residency at one location, and there is no formal system of rotations that would broaden their clinical experience. The Project is failing to meet a sixth goal of following global standards of care (goal #iii) and it is too early to say if it's pioneering approach to residency training is having an impact on healthcare in Japan (goal #vii). On balance, the Project's success in implementing elements of its core philosophy for residency training in the tradition-bound environment of Japan is particularly laudable.

Measuring quality of surgical care: is it attainable?

SUMMARY

Healthcare quality has emerged as an important discussion topic for the American people. With the continued lack of health insurance coverage for over 15 percent of Americans, questions are being posed regarding why the United States has spent $2.1 trillion per year in healthcare and is still unable to provide the highest quality of healthcare in the world. The World Health Organization's 2000 World Health Report ranked the United States at 24 out of 191 member countries in healthcare indices. Because of a looming reduction in the number of Americans covered through the Medicare and Medicaid programs due to budgetary constraints, many initiatives have been proposed to cut the cost of healthcare and at the same time improve the quality of the American system. In this article, the authors summarize the history of these quality initiatives and discuss current and future directions of programs to achieve better healthcare for the country. They also discuss how the American Society of Plastic Surgeons is engaging national organizations to be part of the solution for this crisis.

Quality management and patient safety: survey results from 102 Hungarian hospitals

OBJECTIVES

The aim of this study is to describe the development of quality management systems in Hungarian hospitals. It also aims to answer the policy question, whether a separate patient safety policy should be created additional to quality policies, on national as well as hospital level.

METHOD

In 2005, a questionnaire survey was conducted to evaluate the existing quality management systems in all Hungarian hospitals. The relationship between the level of the development of quality management systems, the certification status and the current level of patient safety activities was investigated using linear regression. Quality was measured with the quality management system development score (QMSDS), and patient safety by the number of patient safety activities.

RESULTS

102 of 134 (76%) of the hospitals have returned the questionnaire. The average hospital has 24.5 of 35 core quality activities, and 4 of 11 patient safety activities. There is a statistically significant but weak relationship between the QMSDS and the number of patient safety activities, explaining 12% of the latter's variance. Certification (International Standards Organisation (ISO) and professional standard based) is not significantly related to patient safety.

CONCLUSIONS

In our study quality by QMSDS is weakly related; however, certification is not significantly related to patient safety. We conclude that separate patient safety policies seem worthwhile to be created for the hospital sector in addition to the ongoing quality improvement efforts in Hungary.

Factors associated with system-level activities for patient safety and infection control

Objective

We examined the relationship between hospital structural characteristics and system-level activities for patient safety and infection control, for use in designing an incentive structure to promote patient safety.

Methods

This study utilized a questionnaire to collect institutional data about hospital infrastructure and volume of patient safety activities from all 1039 teaching hospitals in Japan. The patient safety activities were focused on meetings and conferences, internal audits, staff education and training, incident reporting and infection surveillance. Generalized linear modeling was used.

Results

Of the 1039 hospitals surveyed, 418 (40.2%) hospitals participated. The amount of activities significantly increased by over 30% in hospitals with dedicated patient safety and infection control full-time staff (P < 0.001 and P < 0.01, respectively). High profit margins also predicted the increase of patient safety programs (P < 0.01). Perceived lack of administrative leadership was associated with reduced volume of activities (P < 0.05), and the economic burden of safety programs was found to be disproportionately large for small hospitals (P < 0.05).

Conclusions

Hospitals with increased resources had greater spread of patient safety and infection control activities. To promote patient safety programs in hospitals, it is imperative that policy makers require the assignment of dedicated full-time staff to patient safety. Economic support for hospitals will also be required to assure that safety programs are sustainable.

Cost of hospital-wide activities to improve patient safety and infection control: a multi-centre study in Japan

OBJECTIVE

The aim of this study was to assess the financial costs to hospitals for the implementation of hospital-wide patient safety and infection control programs.

METHODS

We conducted questionnaire surveys and structured interviews in seven acute-care teaching hospitals with an established reputation for their efforts towards improving patient safety. We defined the scope of patient safety activities by use of an incremental activity measure between 1999 and 2004. Hospital-wide incremental manpower, material, and financial resources to implement patient safety programs were measured.

RESULTS

The total incremental activities were 19,414-78,540 person-hours per year. The estimated incremental costs of activities for patient safety and infection control were calculated as US$ 1.100-2.335 million per year, equivalent to the employment of 17-40 full-time healthcare staff. The ratio of estimated costs to total medical revenue ranged from 0.55% to 2.57%. Smaller hospitals tend to shoulder a higher burden compared to larger hospitals.

CONCLUSIONS

Our study provides a framework for measuring hospital-wide activities for patient safety. Study findings suggest that the total amount of resources is so great that cost-effective and evidence-based health policy is needed to assure the sustainability of hospital safety programs.

Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan

Background

In Japan, as in many other countries, several quality and safety assurance measures have been implemented since the 1990's. This has occurred in spite of cost containment efforts. Although government and hospital decision-makers demand comprehensive analysis of these activities at the hospital-wide level, there have been few studies that actually quantify them. Therefore, the aims of this study were to measure hospital-wide activities for patient safety and infection control through a systematic framework, and to identify the incremental volume of these activities implemented over the last five years.

Methods

Using the conceptual framework of incremental activity corresponding to incremental cost, we defined the scope of patient safety and infection control activities. We then drafted a questionnaire to analyze these realms. After implementing the questionnaire, we conducted several in-person interviews with managers and other staff in charge of patient safety and infection control in seven acute care teaching hospitals in Japan.

Results

At most hospitals, nurses and clerical employees acted as the main figures in patient safety practices. The annual amount of activity ranged from 14,557 to 72,996 person-hours (per 100 beds: 6,240; per 100 staff: 3,323) across participant hospitals. Pharmacists performed more incremental activities than their proportional share. With respect to infection control activities, the annual volume ranged from 3,015 to 12,196 person-hours (per 100 beds: 1,141; per 100 staff: 613). For infection control, medical doctors and nurses tended to perform somewhat more of the duties relative to their share.

Conclusion

We developed a systematic framework to quantify hospital-wide activities for patient safety and infection control. We also assessed the incremental volume of these activities in Japanese hospitals under the reimbursement containment policy. Government and hospital decision makers can benefit from this type of analytic framework and its empirical findings.

An eight-year follow-up national study of medical school and general hospital ethics committees in Japan

BACKGROUND

Ethics committees and their system of research protocol peer-review are currently used worldwide. To ensure an international standard for research ethics and safety, however, data is needed on the quality and function of each nation's ethics committees. The purpose of this study was to describe the characteristics and developments of ethics committees established at medical schools and general hospitals in Japan.

METHODS

This study consisted of four national surveys sent twice over a period of eight years to two separate samples. The first target was the ethics committees of all 80 medical schools and the second target was all general hospitals with over 300 beds in Japan (n = 1457 in 1996 and n = 1491 in 2002). Instruments contained four sections: (1) committee structure, (2) frequency of annual meetings, (3) committee function, and (4) existence of a set of guidelines for the refusal of blood transfusion by Jehovah's Witnesses.

RESULTS

Committee structure was overall interdisciplinary. Frequency of annual meetings increased significantly for both medical school and hospital ethics committees over the eight years. The primary activities for medical school and hospital ethics committees were research protocol reviews and policy making. Results also showed a significant increase in the use of ethical guidelines, particularly those related to the refusal of blood transfusion by Jehovah's Witnesses, among both medical school and hospital ethics committees.

CONCLUSION

Overall findings indicated a greater recognized degree of responsibilities and an increase in workload for Japanese ethics committees.

Lag time in an incident reporting system at a university hospital in Japan

BACKGROUND

Delays and underreporting limit the success of hospital incident reporting systems, but little is known about the causes or implications of delayed reporting.

SETTING AND METHODS

The authors examined 6880 incident reports filed by physicians and nurses for three years at a national university hospital in Japan and evaluated the lag time between each incident and the submission of a report.

RESULTS

Although physicians and nurses reported nearly equal numbers of events resulting in major injury (32 v 31), physicians reported far fewer minor incidents (430 v 6387) and far fewer incidents overall (462 v 6418). In univariate analyses, lag time was significantly longer for physicians than nurses (3.79 v 2.20 days; p<0.001). In multivariate analysis, physicians had adjusted reporting lag time 75% longer than nurses (p<0.001) and lag time for major injuries was 18% shorter than for minor injuries (p = 0.011). Adjusted lag time in 2002 and 2004 were 34% longer than in 2003 (p<0.001).

CONCLUSIONS

Physicians report fewer incidents than nurses and take longer to report them. Quantitative evaluation of lag time may facilitate improvements in incident reporting systems by distinguishing institutional obstacles to physician reporting from physicians' lesser willingness to report.

Perspectives in medical education - 4. A "global" dimension to reform at Keio University

Keio University School of Medicine is awakening to the realization that it will achieve international recognition as a center of excellence in medical education and healthcare only by inculcating clinical skills and critical thinking in its medical graduates. A new "global" perspective identifies the traditional failure of Japanese medical education to provide its graduates with clinical skills training as the root cause of a number of deficiencies. These include (i) the reluctance of Japanese medical graduates to seek global experience; (ii) the absence of interest in the global healthcare marketplace for Japanese medical graduates as potential recruits; (iii) the failure to incorporate globally accepted innovations, like problem-based learning, in Japanese medical education; (iv) the failure to follow globally accepted standards of clinical practice in Japan; (v) the lack of instruction in general internal medicine in Japan; and (vi) the neglect of evidence-based medicine in Japanese healthcare practice. Keio University is embarking on an ambitious effort that commits both the will and resources necessary to reform medical education at Keio in accordance with global norms. The initiatives currently underway include (i) incorporating PBL into the curriculum to foster active learning, (ii) implementing measures to promote interactive teaching techniques among the faculty, and (iii) granting recognition to teachers through new promotion policies. Wider implementation of these initiatives across the country will enable Japanese healthcare and Japanese physicians to occupy their rightful place of respect in the global healthcare market, comparable to the widespread international recognition given to Japanese medical researchers.

Functional mapping of hospitals by diagnosis-dominant case-mix analysis

BACKGROUND

Principles and methods for the allocation of healthcare resources among healthcare providers have long been health policy research issues in many countries. Healthcare reforms including the development of a new case-mix system, Diagnosis Procedure Combination (DPC), and the introduction of a DPC-based payment system are currently underway in Japan, and a methodology for adequately assessing the functions of healthcare providers is needed to determine healthcare resource allocations.

METHODS

By two-dimensional mapping of the rarity and complexity of diagnoses for patients receiving treatment, we were able to quantitatively demonstrate differences in the functions of different healthcare service provider groups.

RESULTS

On average, inpatients had diseases that were 3.6-times rarer than those seen in outpatients, while major teaching hospitals treated inpatients with diseases 3.0-times rarer on average than those seen at small hospitals.

CONCLUSION

We created and evaluated a new indicator for DPC, the diagnosis-dominant case-mix system developed in Japan, whereby the system was used to assess the functions of healthcare service providers. The results suggest that it is possible to apply the case-mix system to the integrated evaluation of outpatient and inpatient healthcare services and to the appropriate allocation of healthcare resources among health service providers.

Perspectives in medical education. 3. Reforming medical education to change healthcare practice in Japan

The enviable health status of Japanese citizens is one of the reasons for obdurate opposition to reform of Japanese healthcare practice. Change is widely believed to be unnecessary for a system that is both successful and profitably exploited to universal benefit. However, societal trends are conspiring to make current healthcare practice patterns and expenditures unsustainable in the future. In particular, Japan has undergone an unprecedented demographic shift from a society of young (and healthy) workers to one of older retirees with a higher prevalence of obesity. As a result, an equally dramatic future increase can be anticipated in the prevalence of age- and obesity-related disorders. The traditional paradigm of Japanese healthcare is not conducive to the restraint necessary for preserving its future viability, given these trends. Japanese healthcare does not reward clinical problem-solving skills, values specialists over generalists, places a heavy reliance on expensive technology, does not require interventions to be evidence-based, and provides no incentives to improve quality or efficiency. If this paradigm endures, Japanese healthcare faces the real prospect of bankruptcy. The failure of Japanese medical education to inculcate clinical skills and stress evidence-based medical practice lies at the heart of the impending crisis in healthcare. To solve the crisis, medical education in Japan must change its focus to training and developing a cadre of physicians with the broad-based expertise and clinical skills to make evidence-based decisions in a medically and fiscally responsible manner. The future health of the system and of the Japanese people depends on it.

Quality improvement in the Estonian health system--assessment of progress using an international tool

OBJECTIVE

To assess the quality of the Estonian health system with the assessment tool provided by the World Health Organization (WHO).

DESIGN

Situation analysis of health care quality using the self-assessment questionnaire proposed by the Council of Europe and WHO Regional Office for Europe as a framework for evaluating national quality activities.

SETTING

Estonia.

MAIN OUTCOME MEASURES

Four domains for evaluating the national quality activities: policy, organization, methods, and resources.

RESULTS

The quality policy of Estonian health care developed in the late 1990s defines the scope of quality and reflects the different viewpoints of stakeholders. Nevertheless, it is not comprehensive enough, activities planned for the involvement of consumers in defining and assessing quality are lacking, and key roles of institutions in quality improvement and incentives for quality are not clearly defined. At present, the responsibilities for quality assurance are distributed among the different stakeholders, but there is no single coordinating structure or mechanism for facilitating or assessing the implementation of the quality activities. Many regulations are established to assure the quality of health services and to protect patients' rights, but the implementation of voluntary mechanisms for quality assurance should be promoted. Access to the sources of information is good, but there is a shortage of unified quality and performance indicators at the national level.

CONCLUSION

The results of this study indicated the strengths and shortages of the present organization of quality activities in Estonia and the ways for improvement. Strengthening coordination with explicit quality monitoring was found as a key factor for improvement.

A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation [LP0560737]

BACKGROUND

Accreditation has become ubiquitous across the international health care landscape. Award of full accreditation status in health care is viewed, as it is in other sectors, as a valid indicator of high quality organisational performance. However, few studies have empirically demonstrated this assertion. The value of accreditation, therefore, remains uncertain, and this persists as a central legitimacy problem for accreditation providers, policymakers and researchers. The question arises as to how best to research the validity, impact and value of accreditation processes in health care. Most health care organisations participate in some sort of accreditation process and thus it is not possible to study its merits using a randomised controlled strategy. Further, tools and processes for accreditation and organisational performance are multifaceted.

METHODS/DESIGN

To understand the relationship between them a multi-method research approach is required which incorporates both quantitative and qualitative data. The generic nature of accreditation standard development and inspection within different sectors enhances the extent to which the findings of in-depth study of accreditation process in one industry can be generalised to other industries. This paper presents a research design which comprises a prospective, multi-method, multi-level, multi-disciplinary approach to assess the validity, impact and value of accreditation.

DISCUSSION

The accreditation program which assesses over 1,000 health services in Australia is used as an exemplar for testing this design. The paper proposes this design as a framework suitable for application to future international research into accreditation. Our aim is to stimulate debate on the role of accreditation and how to research it.

Inequity in the price of physician activity across surgical procedures

OBJECTIVES

A rational payment system is being sought in Japanese health care-one that accurately reflects the required time and the level of technical difficulty when valuing physician activity. The objective of this study is to examine the current surgical payment system in Japan by clarifying the hourly values allocated to physician activity.

METHODS

This study focused on the 22 surgical procedures most frequently registered in our study database of administrative data gathered from 11 teaching hospitals in Japan. The current fee-for-service reimbursement system does not formally define which cost components surgical fees cover. It was therefore necessary for us to examine directly each reimbursement item to determine which component it represented. Next we examined the current system from the following viewpoints: (1) variation in the hourly values allocated to physician activity, for an individual surgeon or a surgical team, among types of surgery by using the actual data; (2) the association between the hourly values and the operation time or the level of technical difficulty.

RESULTS

The hourly values allocated to physician activity were low (US dollars 61.0 and 121.5 per surgeon: means of case 1 and case 2 estimations). The hourly values varied inequitably among types of surgery (from US dollars -28 to 237 and from US dollars 6 to 328: ranges in the case 1 and case 2 estimations). When long surgeries were excluded, shorter surgeries tended to have higher hourly values. The association between the hourly values and the difficulty level was less clear and their variation was large even at the same difficulty level.

CONCLUSION

In the current payment system, the surgical fee is deemed to include fee for physician activity as well as materials, equipment and so on. To develop a rational payment system, first, the scope of the surgical fee and that of the physician activity fee should be separated and clearly defined. Second, the latter should be modeled to reflect the manpower volume and the level of technical difficulty needed for each surgical procedure. Third, fees should be set by utilizing the cost estimates with empirical data.

Profiling Hospital Performance of Laparoscopic Cholecystectomy Based on the Administrative Data of Four Teaching Hospitals in Japan

Over the last decade in Japan, laparoscopic cholecystectomy (LC) has replaced traditional open cholecystectomy as the standard of elective surgery for cholelithiasis. The laparoscopic approach has a clinical course relatively easier to standardize among the different types of intraabdominal surgery. However, significant practice variation is suspected in Japan, but there has been little demonstration or discussion based on empirical data. Through the analysis of 1589 elective LC cases from four leading teaching hospitals in Japan between 1996 and 2000, this study aims to demonstrate the surgical variations and to investigate their determinants regarding the length of hospital stay and the health care charge. Substantially and significantly large variation existed among the hospitals in terms of the length of hospital stay and the total health care charge, even after the differences in patient factors were adjusted. Particularly, the combined drug and exam charge per day was strikingly different among the four hospitals, which indicated that the daily process also varied widely, as did the total course of inpatient care. In addition, intra-hospital variation was also remained very large even after adjusting for all the potential correlates studied. This study alarmingly points out great room for improvement in the efficiency of health care resource use and potentially in the quality of care through standardization of LC. It has serious implications for the national policy and individual providers under the on-going health care reforms directed toward higher efficiency and quality.

Estimation of the impact of providing outpatients with information about SARS infection control on their intention of outpatient visit

To examine the effect of provision of information about the infection control in the specific infection disease treatment unit in a city hospital on the outpatient’s intention of outpatient service use, respondents who underwent outpatient medical care at the hospital (N = 821) were asked whether or not they intended to continue the outpatient visit at the hospital if a severe acute respiratory syndrome (SARS) patient was admitted to the unit. Although 56% of respondents replied that they could continue to visit the department if a SARS patient was admitted to the unit in the hospital before they read the information, the proportion of those who intended to continue outpatient care significantly increased by 15% after they read it. The logistic regression analyses revealed that respondents who had frequently visited the outpatient department (P < 0.001), those who felt relieved by reading the information about the unit (P < 0.001), and those who did not worry about nosocomial SARS infection inside the hospital (P < 0.001) were significantly more likely to reply that they would continue outpatient visits. We estimated that admission of a SARS patient to the unit would result in a 20% decrease in the cumulative total number of outpatients in the hospital during a 180-day interval after admission of a SARS patient to the unit, and the cumulative total number of outpatients increased by 7% after they read the information. This study suggests that providing outpatients with appropriate information about SARS infection control in the hospital had a statistically significant and substantial impact on the outpatients’ intention to continue outpatient visits at the hospital.

Association of hospital resource use with comorbidity status and patient age among hip fracture patients in Japan

OBJECTIVES

This study examined the association of resource use with comorbidity status and patient age among hip fracture patients who underwent surgical treatment.

DESIGN

We used a database from the Voluntary Hospitals of Japan Quality Indicator Project that involved 10 privately owned leading teaching hospitals in Japan.

SETTING

Four of these hospitals in Japan.

PARTICIPANTS

We selected 778 operable hip fracture patients aged 65 or older who were admitted to these hospitals between January 1996 and August 2000 (mean age: 80.3 +/- 7.3 years).

MEASUREMENTS

A linear mixed model was performed to identify factors associated with the resource use, such as total length of stay (LOS), LOS before surgery, LOS after surgery, total hospital charges, charges for diagnostic examinations, charges for surgery, and length of theater time, among operable hip fracture patients.

RESULTS

The mean LOS was 45.9 days, and the mean total hospital charges were US dollars 14,495.0. Results from linear mixed models revealed that higher age was significantly associated with shorter length of theater time (P < 0.01), and that the presence of comorbidity among hip fracture patients was significantly associated with longer total LOS (P < 0.01), longer LOS after surgery (P < 0.001), higher charges for diagnostic examinations (P < 0.001), and shorter length of theater time (P < 0.01).

CONCLUSION

These results suggest that the presence of comorbidity among operable hip fracture patients requires greater resource use during their hospital stay, but higher age is not significantly associated with greater resource use at all.