《ISQUA2023-ABS-1426》

Nationwide initiatives to spread andpromote improvement activities using
healthcare quality indicators in Japan
K.Jimbo *1, T.Kameda *1,3, H.Sugawara *1, M.Matoba *2*1 Japan

Council for Quality Health Care, *2 Showa University *3 Medical Corporation Tesshokai

Japan Council for Quality Health Care

Intoroduction
The Japan Council for Quality Health Care (JQ) was established in 1995 as an independent, non-profit organization which aims to improve
Japan's health care and welfare. As a neutral and scientific third-party organization, carries out projects to improve the quality ofhealthcare and ensure reliable healthcare.

JQ has started a new project that aims to improve the quality of healthcare using indicators. Efforts using quality indicators in Japanare limited to the activities of pioneering hospitals and some hospital association, and nationwide dissemination is an issue.
Therefore, this project started in 2019 with the cooperation of Ministry of Health, Labour and Welfare (MHLW) and hospital association,
aiming to spread the use of quality indicators nationwide.

ObjectiveResults

This study provides an overview of the state ofhealthcare quality in Japan, based on theresults of a nationwide measurement campaignthat utilizes quality indicators.

Figure 1 shows the distribution of measurement results for the three indicators
related to patient safety. MSM-01 shows a large variability (SD=1.171), and MSM-02
is low throughout (Median=0.070). However, it should be noted that the unit of MSM01 and MSM-02 is "permillage (‰)". In addition, MSM-03 is high overall(Median=93.490),but varied widely (SD=5.904).

In addition, we will consider various issues
related to quality indicators that have become
clear from the campaign.

(N=271)(N=231)SD=1.171

SD=0.051(N=172)SD=5.904

Methods
Cooperation in the measurement campaign isvoluntary. Cooperation hospitals measure a
total of nine indicators related to patient
safety, infection control, and patient carebased on common procedures, and submit thedata.

In this study, of the submitted data (Number ofhospitals N=287), we analyzed the measurement
data of 3 indicators related to patient safety
from October 2021 to March 2022.
The analysis was performed by bed size ((a) 199
beds or less, (b) 200 to 399 beds, (c) 400 bedsor more) and compared between bed sizes.
The three indicators related to patient safety
are "MSM-01: Rate of fall among in-hospitalpatients," "MSM-02: Rate of fall-related
injuries among in-hospital patients," and"MSM-03: Rate of implementation of preventive
measures for pulmonary thromboembolism inpatients who operated high-risk surgery.”.

Figure 1 The distribution of measurement results for the three indicators related to patient safety.

Figure 2 shows the measurement results of three indicators related to patientsafety by bed size ((a),(b),(c)). A significant difference was observed group (b)and (c) in MSM-01 (p=0.010), group (a) and (c), group (b) and (c) in MSM-02 (bothp<0.001). In addition, a significant difference was observed group (b) and (c) inMSM-03 (p=0.025).

p=0.010*(a)N=78(b)N=80(c)N=96(a)N=60(b)N=75(c)N=85

p<0.001*p<0.001*p<0.025*(a)N=44(b)N=64(c)N=78Figure 2 the measurement results of three indicators related to patient safety by bed size ((a),(b),(c)).
* Different letters indicate significant differences by Bonferroni test (p<0.05)

Conclusion
As a result of verifying the three indicators related to patient safety, these were observed to the trend that the larger the hospital
bed size, the smaller the variation in the measured and the higher measured, which was particularly evident in the “Rate of fallrelated injuries among in-hospital patients (MSM-02)” results. It seemed to affect the results to the difference in organizational
structure and management depending on the size of the hospital bed. “Rate of implementation of preventive measures for pulmonary
thromboembolism (MSM-03)” observed significant difference between 200 and 399 beds and 400 and more beds, and the former group was alarge variation. It suggested that there was possible room for improvement in the standardization of the care process in these groups.
On the other hand, the data used for measurement include standardized data (MSM-03) and non-standardized data (MSM-01, MSM-02), so caremight be taken in interpreting the results. In addition, this study suggested that there was the need to use standardized data for moreaccurate measurements and to consider for workload of measurements in order to spread the use of quality indicators on a nationwide.

NoticeThis study is limited, because
it used mid evaluation report.

References
Essential guide for Quality Indicators in Healthcare
in Japan.Japan Council for Quality Health Care 2021

Contact Information
Improvement project for enhancing
healthcare quality,powered by JQ.
https://jq-qiconf.jcqhc.or.jp/