Annual Report 2024

Quality Management Section

Yuji Nishizawa, Sayaka Ishiwata

Introduction

 The Quality Management Section collects and analyzes clinical indicators (CI) related to patient safety, quality of care, and hospital management, and drives cross-departmental improvement initiatives based on data-driven metrics. Currently, 55 CIs are compiled and shared through various institutional bodies such as the Management and Quality Management Committee. Each fiscal year, we also set specific CI targets and serve as a project manager to promote hospital-wide quality improvement activities.

 In collaboration with the National Cancer Center Hospital, we standardized the definitions of 36 CIs, enabling direct comparison and joint analysis between the two institutions. We are working to develop new evaluation metrics for cancer-specialty hospitals by creating and refining cancer-specific clinical indicators.

The Team and What We Do

 We drive repeated cross-departmental collaboration that sparks organization-wide synergy.

Research Activities

 Figure 1 shows the trends in clinical pathway (CP) utilization rates, with both internal medicine and surgical departments achieving their target values in FY2024. Centered on the CP Working Group, each department established and revised CPs, and various initiatives were implemented to promote their use. Furthermore, by aligning CP development with DPC (Diagnosis Procedure Combination) periods, more precise bed management became possible.

 Table 1 presents an excerpt of the CIs standardized with the National Cancer Center Hospital. These unified indicators have been utilized in quality improvement activities at both hospitals since FY2024.

Figure 1. Trend in Clinical Pathway Application Rate (annual avg.)

Table 1. Excerpt of CIs Standardized with the NCCH

Education

 In cross-organizational quality improvement activities, repeated collaboration among departments is essential to achieving coordinated action. For each project, we coordinate with relevant departments, encourages participation, and builds a structure in which multiple departments work together toward common goals.

 In FY2024, an in-house seminar was held to deepen understanding of the importance of quality management and future-oriented improvement initiatives, covering topics such as healthcare system reform and the role of cancer-specialty hospitals in regional healthcare.

Future Prospects

 Because CIs for cancer-specialty hospitals are often difficult to compare with those of general hospitals, we plan to develop CIs tailored to cancer-specialty hospitals and to establish a collaborative system that enables these hospitals to share CIs and conduct benchmarking.

 Building on the CIs standardized with the National Cancer Center Hospital, we aim to develop a framework that allows the collection of CIs from cancer-specialty hospitals nationwide.