Annual Report 2023
Quality Management Section
Yuji Nishizawa, Sayaka Ishiwata
Introduction
The Quality Management Section (QM) collects and analyzes clinical indicators (CI) related to medical safety, medical quality, and hospital management, and uses the data as indicators to implement cross-organizational improvement activities. Currently, 54 CIs are collected and publicized at quality management meetings. Target CIs are set each year, and improvement activities are implemented throughout the hospital with QM acting as the project manager.
The Team and What We Do
We manage cross-organizational improvement projects based on CIs.
Research Activities
Tables 1 and 2 show the target CIs for fiscal year 2023 and their results. As a result of improvement activities led by the Department of Nursing, the target waiting time for blood collection was achieved. As a part of efforts to improve outpatient waiting times, since fiscal year 2020, we have been operating the outpatient scheduling desk where the medical assistants plan test and examination orders on behalf of medical doctors. As the number of cases handled by the outpatient scheduling desk increased, outpatient waiting times improved (Figure 1), and the target value was achieved.
Table 1. FY2023 Management Clinical Indicators
Table 2. FY2023 Quality Clinical Indicators
Figure 1. The rate of outpatient waiting times over 1 hour (annual avg.)
Education
Cross-sectional improvement activities require collaboration between departments, and we coordinate with relevant departments for each project. We continually educate our hospital staff on the need for quality management and to involve them in improvement activities. In FY2023, we held study sessions on improvement activities and clinical pathways.
Future Prospects
The CIs of a cancer specialty hospital are difficult to compare with that of a general hospital. Therefore, we would like to set CIs specialized for cancer specialty hospitals and plan to share them with cancer hospitals.