Annual Report（April 2022 - March 2023）

June 2023
Japan Council for Quality Health Care0

Index[ 1 ] Hospital Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2[ 2 ] The Japan Obstetric Compensation System for Cerebral
Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
[ 3 ] EBM and Clinical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30[ 4 ] National Database of Medical Adverse Events . . . . . . . . . . . . . .36[ 5 ] Patient Safety Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44[ 6 ] Education and Training for Health Care Professionals. . . . . . . . . . .49[ 7 ] Other Projects to Achieve the Purpose of JQs with Japanese
Government
1. Improvement Project for Enhancing Health Care Q uality(Quality Indicators) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2. Research on ICT-Based Medical Education Contents Based on
Clinical Practice and on Computer-Based Testing for the
National Medical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
[ 8 ] Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

1

【１】Hospital Accreditation
I．Hospital Accreditation
１．Current status for hospital accreditation and support（１）Accreditation status in Japan
As of March 31, 2023, the number of accredited hospitals was 2,013 out of 8,182
hospitals (24.6%). The number of accredited beds was 614,003 (41.0%).

Table 1: Status of Accredited Hospitals (as of March 31, 2023)
Number of
hospitals

Number of beds

Total number of hospitals※

8,182

1,496,856

Accredited hospitals

2,013

614,003

Accreditation rate

24.6%

41.0%

Previous year (number)

2,043

619,486

Previous year (rate)

24.8%

41.1%

Year-on-year change

98.8%

99.0%

Source: "Survey of Medical Institutions (approximate figures as of the end of※

March 2022)" (Ministry of Health, Labour and Welfare)

Figure 1: Trends in number of survey and accredited hospitals (as of March 31, 2023)

The accreditation status by functional category shows that for mainfunctions, General Hospital 2 had the largest number of hospitals with 957,
followed by General Hospital 1 with 550. On the other hand, for subfunctions, Rehabilitation Hospitals had 205 hospitals, Palliative Care
Hospitals had 103, followed by Chronic Phase Hospital with 83, andPsychiatric Hospital with 75 hospitals (Table 2). Note that the total numberof hospitals is a tally count since some hospitals undergo evaluation for
multiple function types as sub-functions.
2

Table 2: Number of Accredited Hospitals by Functional Category(as of March 31, 2023; reprinted)
Functional category

Main

Sub

functionfunction

General Hospital 1

516 (25.6％)

34

550

General Hospital 2

950 (47.2%)

7957

General Hospital 3

68 (3.4%)－

68

Rehabilitation Hospital

145 (7.2%)

205

350

Chronic Care Hospital

148 (7.4%)

83

251

Psychiatric Hospital

173 (8.6%)

75

248

Palliative Care Hospital

13 (0.6%)

103

116

2,013 (100%)

507

－

Total

Total
※

The number of accredited hospitals through Advanced and Specialized
Functions evaluations or additional function evaluations was 24 for“emergency medical care and disaster medical care" and 63 for“convalescent rehabilitation" (Table 3) as of March 31, 2023. Compared tothe previous year, there was an increase of 2 hospitals for "emergency
medical care and disaster medical care" and a decrease of 2 hospitals for"Rehabilitation (recovery phase)". Note that the on-site surveys for
additional function evaluations ended on September 30, 2019.
Table 3: Number of accredited hospitals for Advanced and Specialized Functions(as of March 31, 2023)
Functional category
Advanced/Specialized

Emergency Medical Care
Disaster Medical Care

Rehabilitation(Recovery phase)

Total

16

29

45

Certification

8

34

42

Total

24

63

87

Accredited Hospitals

22

65

87

100%

96.9%

100%

Function(previous year)
Year-on-Year
Comparison

Regarding the status of accredited hospitals by bed numbers, theaccreditation rate for hospitals with 800 to 900 beds was the highest at
93.1%, followed by 83.6% for hospitals with 600 to 700 beds (Table 4).
Additionally, the accreditation rates for hospitals based on theestablishers were 100% for National Health Insurance Associations,
84.4% for Workers' Health and Safety Organizations, and 76.1% for
National University Corporations (Table 5).
3

Table 4: Status of Accredited Hospitals by Bed Capacity (as of March 31,2023; reprinted)
Bed Capacity
National※

Accredited

Accreditation

Hospitals

Rate (%)

Accredited

Year-on-

Hospitals

Year(Last year)

Comparison

0 - 99

2,956

234

7.9

239

-5

100 - 199

2,786

583

20.9

602

-19

200 - 299

1,032

315

30.5

324

-9

300 – 399

674

330

49.0

330

0

400 -499

366

237

64.8

232

+5

500 – 599

162

127

78.4

129

-2

600 -699

110

92

83.6

88

+4

700 - 799

38

28

73.7

32

-4

800 – 899

29

27

93.1

26

+1

900 -

52

40

76.9

41

-1

Total

8,205

2,013

24.5

2,043

-30

※

Source: "Survey of Medical Institutions (Dynamic) in 2021" (as of October 1, 2021;
Ministry of Health, Labour and Welfare)4Year-on-year
0

140

60

42.9%

59

+1

46

35

76.1%

33

+2

32

27

84.4%

27

0

57

20

35.1%

23

-3

19

0

0.0%

0

0

Prefectures

196

93

47.4%

103

-10

Municipalities

603

211

35.0%

212

-1

114

63

55.3%

48

+15

91

59

64.8%

61

-2

83

44

53.0%

44

0

100

45

45.0%

47

-2

7

2

28.6%

2

0

Foundercomparison(Previous ye ar)9

Accredited Hos pit als

40.9%

Accreditation rate (%)

Accredited Hos pit als
9

Number of Hospitals

22

Cate g o r y

in Japan ※Table 5: Status of Accredited Hospitals by Founder(as of March 31, 2023)

Minist ry of Health, Labour andWelfare, National Center for
Advanced Medical Res earch
and Technology
Independent

Administrative

Institut ion National Hos pit al
Organizat ion

National

National

Univers ity

Corporation
Independent

Administrative

Institut ion

Occupational

Safetyand

HealthofRegional

nat ional

institutions

Organizat ion
Promotion
Medical Care
Other

(Minist ry of Defens e, Minist ry
ofInternal

AffairsandCommunications , etc.)

Local Independent Administrative
Institutions
Japanese

Red

Cross

Society

Public(Japanese Red Cross)Japanese Society of Social Welfare(Japan Welfare Federation)
Japanese Federation of Medical
ServiceOrganizations(JapanMedical Service Federation)
Other public medical institutions(such as Hokkaido Social Welfare
Association)
5

Health insurance associations and

7

3

42.9%

3

0

39

27

69.2%

27

0

1

1

100.0%

1

0

Public interest corporations

195

112

57.4%

121

-9

Medical corporations

5,671

1,034

18.2%

1,055

-21

Educational corporations

113

69

61.1%

69

0

Companies

27

15

55.6%

17

-2

486

77

15.8%

75

+2

Individuals

133

7

5.3%

7

0

Total

8,182

2,013

24.6%

2,043

-30

insurance

Socialother federations
Mutual aid associations and theirfederations
National

healthinsurance

Otherassociations

Other corporations (such as social
welfare corporations)

Source: "Survey of Medical Institutions (Preliminary Figures as of the end of March,※2022)" (Ministry of Health, Labour and Welfare)

Table 6 shows the accreditation status by designated hospitals. The
accreditation rates of these hospitals, including hospitals that haveapplied for accreditation, have improved due to the impact of becoming
accreditation as the mandatory requirement for the medical
remuneration for Acute Care Enhancement System, the effort-based
requirements for the type of Inpatient Fees 1 and 3 for Recovery
Rehabilitation Units, and the mandatory requirement for the regional
cancer treatment base hospitals by reviewing the requirements for basehospitals for cancer treatment.

6

Acute Care Enhancement
SystemConvalescent
Rehabilitation Unit 1
Convalescent
Rehabilitation Unit 3
Advanced Treatment
Hospital
Regional Medical Care
Support Hospital
Cancer Care Hub Hospitals(Prefecture)
Cancer Care Hub Hospitals(Regional; Advanced Type)
Cancer Care Hub Hospitals(Regional)
Cancer Care Hospitals(Regional)(%)

for previous year

Accreditation rate(%)

Accreditation Rate

Hospitals ※1

Accredited

Hospitals

Classification

Total Number ofTable 6: Accreditation Status by Designated Hospitals (as of March 31, 2023)

-

177※2

168

94.9

950※2,※3

595

62.6

52.8

307※2,※3

111

36.2

32.9

88※4

81

92.0

92.0

681※5

601

88.3

82.0

51※6

48

94.1

94.1

55※6

54

98.1

98.1

293※6

274

93.5

87.4

45※*6

27

60.0

62.2

※1

Including hospitals that have applied for accreditation.

※2

Source: List of Medical Institutions Registered with the Local Health Bureau(as of February 1, 2023, March 1, 2023, and April 1, 2023)※3

Hospitals that have obtained both Inpatient Fee 1 and 3 for Convalescent
Rehabilitation Units were recorded under Inpatient Fee 1 only.

※4

Source: Approval Status of Specific Function Hospitals (as of December 1, 2022;
Ministry of Health, Labour and Welfare)https://www.mhlw.go.jp/content/10800000/001018536.pdf※5Source: Websites of each prefecture (and some cities) as of April 1, 2023.※6

Source: List of Cancer Treatment Collaboration Base Hospitals, etc. (as ofApril 1, 2022; Ministry of Health, Labour and Welfare)https://www.mhlw.go.jp/content/000921256.pdf（２） Accreditation Status for the Fiscal Year 2022
A. Regular survey (Main function, sub function)
In the fiscal year 2022, we conducted 448 on-site surveys for the mainfunction (28 new hospitals, 420 renewals) and 105 for the sub function
7

(Table 7-2). Due to the impact of the COVID-19 pandemic, the monthly
on-site survey rate decreased to less than 40% at its lowest, but theoverall rate for the year was 79.6%. The conditions for conducting onsite surveys are as follows: (1) The hospital can accommodate the onsite survey; (2) A surveyor team can be formed; and (3) The risk ofsurveyors being exposed to the COVID-19 during the on-site survey is
low.
Table 7-1: Number of on-site surveys conducted in fiscal year 2022 (byNew and Renewal)
TargetResultAchievement rate

New:

50

28 (6.7%)

56.0%

Renewal:450

420 (93.3%)

93.3%

Total:

500

448 (100%)

89.6%

Table 7-2: Number of on-site surveys conducted in FY 2022
(by type of function; repeated)
Main

Sub

Function

Function

Total

General Hospital 1

113 (25.2%)

7120

General Hospital 2214 (47.8%)

1215

General Hospital 3

24 (5.4%)-

24

Palliative Care

1 (0.0%)2829

Chronic Care24 (5.4%)

16

40

Mental Health

36 (8.1%)

13

49

Rehabilitation

36 (8.1%)

40

76

Total

448 (100%)

105-

The renewal refusal rate for hospitals eligible for renewal in FY 2022
was 13.6% (Figure 2). The renewal refusal rate is showing a tendency
to improve due to the exceptional measures related to the COVID-19
pandemic and revisions to medical fee schedules. It should be notedthat there are hospitals that have postponed their renewal surveys due
to special exception so the refusal rate for fiscal years after 2020 isprovisional.

8Figure 2: Trends in Rate of Refusal to Renew (as of March 31, 2023)

B. Evaluation of Advanced and Specialized Functions
In fiscal year 2022, a total of 19 hospitals underwent on-site survey foradvanced and specialized functions, with 8 hospitals for "Emergency
Medical and Disaster Medical Care" and 11 hospitals for "Convalescent
Rehabilitation " (Table 8).
Table 8: Number of Hospitals Undergoing Evaluation for
Advanced and Specialized Functions
Year-on-YearType

NumberEmergency Medical and Disaster8

3 (+5)

Convalescent Rehabilitation11

9 (+2)

Total

19

12 (+7)Comparison

Medical Care

C. Mid-term review
Since fiscal year 2015, "mid-term review" has been conducted for
accredited hospitals under Hospital Accreditation Standards 3rdG:
Ver.1.0. 221 out of 341 hospitals (64.8%) submitted the mandatory "selfassessment sheet," and 15 hospitals (4.4%) submitted the optional"quality improvement activity report sheet," totaling 35 cases.
Table 9: Mid-term Review Submission Status
Number of Hospitals
Targeted Hospitals

341

Self-Assessment Submission

221（64.8%）(Required)

9Quality Improvement Activity

15 (4.4%)

Case Report (Optional)(35 cases)（３）Results of the 2022 Accreditation Support Activities
A. Seminars (Online)
For the seminars in the 2022 fiscal year, we provided real-timestreaming or recorded streaming (Table 10). Note that the seminars
numbered 3-13 were published before the FY2021. Hospitals can watch
these seminars for one year from the date of registration.
Table 10: Seminar Application Results (as of March 31, 2023)
Number ofNo

Seminar Titles

Date of Publication

Hospitals
Applying

1

Improvement

SupportSeminarNov 2, 2022

149

SupportSeminarDec 1, 2022

113

SupportSeminaralready distributed

70

SupportSeminaralready distributed

20

SupportSeminaralready distributed

46

Seminaralready distributed

51

Seminaralready distributed

25

Seminaralready distributed

35

Improvement Support Seminar (Carealready distributed

47

already distributed

42

already distributed

14

already distributed

5(General) Ver. 3.0(Live Streaming)
2

Improvement(General) Ver. 3.0(On-demand Streaming)
3

Improvement(General) Ver. 3.0

4

Improvement(General) Ver. 2.0

5

Improvement(Nursing) Part 1: Basic course
6

Improvement

Support(Nursing) Part 2: Practical course
7

Improvement

Support(Administrative Management)
8

Improvement

Support(Medical Practice)
9

Process Session for medical wards)
10

Improvement Support Seminar (CareProcess Session for surgical wards)

11

Improvement Support Seminar (CareProcess Session for Community-based
Integrated care ward)

12

Improvement

SupportSeminar(General 3)

10

13

Advanced

Specialty(Emergency,

already distributed（不明）

Rehabilitation) *Total (Number of Hospitals Participating)637

The number of hospitals applying is unavailable due to the free public access.

※B. Group Consultation Sessions (online)
The group consultation session (online) is that surveyors respond toinquiries from the hospital preparing for on-site survey. We had 2
sessions for the type of general hospital 3, and 7 sessions for theother hospital types in FY2022. Additionally, we started a new "Group
Consultation Session for New Hospital" specialized for newly applied
hospitals and held 5 times. 139 newly applied hospitals participated in
total.
Table 11: Status of Online Accreditation Consultation Sessions(As of March 31, 2023)
Type

Times

Number of
hospitals

General Hospitals 32

25

Hospitals other than

7

272

5

139

14

436

General Hospitals 3
Consultation Sessions for
New Hospital (NEW)Total

C．Other Supports
Lecturer dispatch, surveyor dispatch, and online support were
provided as shown in Table 12.
Table 12: Status of other supports (as of March 31, 2023)
Type of support
Lecturer Dispatch

Number of cases

Lecture type18

Hands-on6

experience*
Surveyor Dispatch
Online support

Follow-up type*10

Half day

45

1 day

65

Total

34

110

2 Surveyors(Medical + Nurse)

13

Or 1 Medical
1 Surveyor

5

11

18

(Administrator)
Total

162

Implemented as Surveyor Dispatch from October 2022※

D．Cooperation with Prefectural Hospital Associations, etc.
We held 12 seminars on Hospital Accreditation in cooperation withprefectural hospital associations and various related academic
societies in FY2022 (Table 13).
Table 13: Cooperation with Prefectural Hospital Associations and Other
Organizations (as of March 31, 2023)
No.

Affiliations
Annual1

MeetingoftheDate held

Japanese

AssociationofRehabilitation Medicine

Jun 25, 2022

2

Hokkaido Hospital Association

Jul 16, 2022

3

Annual Meeting of All Japan Hospital Association

Oct 1-2, 2022

The Fall Meeting of the Japanese Association of

4

Rehabilitation Medicine
Annual Congress of Japanese Society for Quality and5

Safety in Healthcare

Nov 4-6, 2022

Nov 26, 2022

6

Aichi Medical Corporation Association

Nov 29, 2022

7

Shiga Prefecture Hospital Association

Jan 11. 2023

8

Ishikawa Hospital Society

Jan 28, 2023

9

Shizuoka Hospital Association

Jan 30, 2023

10

All Japan Hospital Association

Feb 12, 2023

11
12

Association of convalescent and rehabilitation wards

Feb 24-

research conference

25,2023

Niigata Hospital Association (consultation)

Mar 1, 2023

E．Publicity
One special issue and one regular issue of the leaflet “Improve” were
published to introduce good practices of improvements in accredited
hospitals.
Table 14: "Improve" published in FY2022
Vol.

Prefecture and name of

Functional category

Month of Issue- Saitama Red Cross Hospital

Advanced and specialized

April 2022

(Saitama Pref.)functions (emergency and

Hospital
-

12

Vol.

Prefecture and name of

Functional category

Month of Issue

Hospital- Iwate Central Hospitaldisaster medical care)(Iwate Pref.)- Kyoto Medical Center(Kyoto Pref.)27

Kodaira Hospital

General Hospital 1

March 2023

(Saitama Pref.)２. Hospital Functional Improvement Support Project（１） Patient satisfaction and employee satisfaction
A．Number of participating hospitals
This program provides a survey system for patient employee
satisfaction via the Internet to participating hospitals. We also holdseminars to share good practices of participating hospitals. Total 329
hospitals participated in FY2022. Table 15 and 16 show thecomposition of the member hospitals and hospitals joined in thebenchmarks, respectively.
Table 15: Participating Hospitals in Patient Satisfaction and Employee Satisfaction
in FY2022
BenchmarkNo.
Definition
Hospitals
Category
General (Small)
Hospitals accredited with "General Hospital1" and only has general beds
1
40
Hospitals accredited with “General Hospital2” and has less than 200 beds
General (Medium)
Hospitals accredited with “General Hospital2
122
2” with 200 to 500 beds
General (Large)
Hospitals accredited with “General Hospital2” with over 500 beds
3
87
Hospitals accredited with "General Hospital3"
Long-term Care
Hospitals accredited with " Long-term Careand Care Mix", "Palliative Care"
4
43
Hospitals accredited with “General Hospital
1” and has beds other than general beds
Rehabilitation
Hospitals accredited with "Rehabilitation
5
26
Hospital"
Psychiatric
Hospitals accredited with "Psychiatric6
11
Hospital”
Total
329※ Categories are classified based on the "main functional category " and thenumber of beds in the hospital accreditation.

Table 16: Hospitals joined in the benchmark FY2022
13

FY2022 1st

FY2022 2nd

BenchmarkBenchmarkTarget Period

Jul 1–Sep 30, 2022

Oct 1–Dec 31, 2022

Date of release of benchmark results

Oct 6, 2022

Jan 6, 2023

Inpatient Satisfaction Survey:

52 hospitals

152 hospitals

Number of hospitals and cases(18,440 cases)(43,390 cases)

Outpatient Satisfaction Survey:

40 hospitals

142 hospitals

Number of hospitals and cases(17,583 cases)(70,198 cases)

Employee Satisfaction Survey:

62 hospitals

170 hospitals

Number of hospitals and cases(24,364 cases)(79,961 cases)

14

B．Sharing Good Practice
We held 2 seminars in September 2022 and February 2023,
introducing good practices of quality improvement in participating
hospitals. We also held a symposium at the 60th Annual Meeting of
the Japan Society for Healthcare Administration. In addition, we
published 5 reports (Vol. 30-34) which presented in these seminars.
C．Annual Report
In May 2022, we published the annual report summarizing theresults for FY2021. Full text (booklet) and PDF were provided toparticipating hospitals. A summary PDF is posted on the website.
（２）Survey for Patient Safety Culture
A．Number of participating hospitals
To support hospitals’ continuous quality improvement based on data,
we provide a web survey system for survey on patient safety culture
surveys and hold seminars to share good practices of member
hospitals. The number of participating hospitals was 72 in FY2022.
Table 17 and 18 show the composition of the member hospitals andhospitals joined in the benchmarks, respectively.
Table 17: Participating Hospitals in Survey on Patient Safety Culture in FY2022
BenchmarkNo.
Definition
Hospitals
Category
General (Small)
Hospitals accredited with "General Hospital 1"
and only has general beds
1
8
Hospitals accredited with “General Hospital2” and has less than 200 beds
General (Medium)
Hospitals accredited with “General Hospital2
25
2” with 200 to 500 beds
General (Large)
Hospitals accredited with “General Hospital2” with over 500 beds
3
29
Hospitals accredited with "General Hospital3"
Long-term Care and Hospitals accredited with " Long-term Care ",Care Mix"Palliative Care"
4
6
Hospitals accredited with “General Hospital 1”
and has beds other than general beds
Rehabilitation
Hospitals accredited with "Rehabilitation
5
3
Hospital"
Psychiatric
Hospitals accredited with "Psychiatric6
1
Hospital”
Total
72※ Categories are classified based on the "main function type" in the hospitalaccreditation and the number of beds.
※ At the time of benchmarking, rehabilitation, medical treatment/care mix, andpsychiatry were collectively calculated as medical treatment/care mix for15

convenience.

Table 18 Hospitals joined in the benchmark FY2022
BenchmarkParticipantsNo.

Benchmark Category

Participating Hospitals

1

General (small scale)

8

8

2

General (medium size)

25

23

3

General (large scale)

29

26

4

Long-term Care and Care Mix

65

Psychiatric3

6

Rehabilitation

1

Total

72

9

66

B．Sharing Good Practice
We held 2 seminars in August 2022 and February 2023. We also
had a panel discussion session in the 17th Annual Congress ofJapanese Society for Quality and Safety in Healthcare. In addition,
we published 4 reports (Vol. 9-12) which presented in these seminars.
C．Annual Reporting
In May 2022, we published the annual report summarizing theresults for FY2021. Full text (booklet) and PDF were provided toparticipating hospitals. A summary PDF is posted on the website.
（３）Work Environment Improvement Support
We held two seminars on improvement of work environment to sharegood practices to improve the work environment using the results of
employee satisfaction surveys, survey on patient safety culture survey,
and stress checks.
Table 19 Participating Hospitals to “Work environment improvement seminar”
DateLive streaming

Recorded

Aug 2, 2022

68 hospitals (71 people)

127 hospitals (151 people)

Jan 24, 2023

50 hospitals (60 people)

106 hospitals (119 people)

３．Survey results (Division of Accreditation)（１）Regular survey (the on-site survey)
A．Number of Surveys
On-site survey (Regular survey) of the "main function" by functional
category evaluation item 3rdG:Ver.2.0 was conducted in 448 hospitals.
16

Table 20 Number of surveys by new/renewal and main function
New/ renewal

RegularNew

Renewal

Total

28

420

448

survey（Unit：Hospital）

Main function
By mainfunction
Regular

G1

G2

G3

Reh.

L.

Psy.

Pal.

113

214

24

36

24

36

1

Total

448

survey（Unit：Hospital）（G1:General Hospital 1,G2:General Hospital 2、G3:General Hospital 3, Reh.:Rehabilitation hospital,
L.:Long-term care hospital, Psy.:Psychiatric hospital, Pal.:Palliative care hospital）

Of the 448 hospitals that underwent the regular survey, 96 hospitals(105 functions) underwent both main and sub-functions.
An additional survey of provisional accreditation hospitals was
carried out in 17 hospitals. In addition, an additional survey of hospitals
withholding accreditation was carried out in 5 hospitals.
An Additional survey for recommendations was carried out in 25
hospitals. This survey is to be conducted in the third year after theaccreditation start date for those hospitals that have undergone onsite survey in the functional category accreditation criteria
3rdG:Ver.2.0. on or after April 1, 2018, and for which the assessment
criterion was rated C in the main functional category.
B．Accreditation decision
The decision on the accreditation of the 'primary function' of 383
hospitals was discussed.
Table 21 Status of accreditation of main functions(Unit: Hospitals)
Accredited

17

Withheld

Total

FullyProvisionally

Accredited

accredited

362

19

2

383

(New)

30

0

2

32

(renewal)

332

19

0

351

RegularsurveyThe 362 accredited hospitals received accreditation certificate valid
for five years. The 19 provisionally accredited hospitals were requested
to submit improvements on the recommendations and to undergo averification survey before the expiry date of their accreditation.
The 2 hospitals, whose accreditation was withheld, were requested
to submit improvements on the recommendations without issuing an
accreditation certificate and to undergo the additional survey of
hospitals withholding accreditation within six months. Of theaccredited hospitals, 93 were accredited for both their main function
and their sub-function. 17 hospitals underwent an additional survey ofprovisional accreditation hospitals, 15 of which had their provisional
accreditation canceled and were issued an accreditation certificate
valid for 5 years. In addition, as a result of the additional survey ofprovisional accreditation hospitals, the 2 hospitals whose
accreditation was withheld were given recommendations without
issuing an accreditation certificate, and were requested to undergo an
additional survey of hospitals withholding accreditation within 6months.
In the survey of hospitals withholding accreditation, 5 hospitals wereaccredited and issued certificates valid for 5 years.
（２）Advanced/specialized functions
A．Number of SurveysSurvey Number
We visited 8 hospitals for emergency medical care and disastermedical care Ver.1.0, and 11 hospitals for rehabilitation (recovery)Ver.1.0.
There were no cases of 2nd survey /verification survey foradvanced/specialized functions.
*2nd survey: the additional survey of hospitals withholding accreditation
Verification survey: the additional survey of provisional accreditation hospitals

B．Accreditation decision18

9 hospitals were accredited for Emergency and Disaster Medicalcare Ver.1.0, and Rehabilitation (recovery) Ver.1.0 accreditation was
granted to 11 hospitals. The accredited hospitals were issued
certificates of advanced and specialized functions valid for five years.
（３）Medical Adverse Event Reports and Medical Safety Surveys fromaccredited hospitals
It requires accredited hospitals to report in the following cases :those covered by the "Operating Guidelines for Hospital Accreditation
21 Attachment 3" and "(1) medical accidents that are highly likely to becaused by deviations from routine accreditation conditions, or(2)medical accident that may cause a significant loss of social
credibility."
A．Number of reports
Twenty medical adverse event reports were submitted byaccredited hospitals.
B．Accreditation decision
Decisions on accreditation were taken in 17 cases, andaccreditation was continued in all cases.
（４）Preparation of hospital accreditation data bookIn fiscal 2021, we compiled the results of the surveys of 282
hospitals that decided whether or not to approve the accreditation
based on our accreditation criteria, the functional category evaluation
item 3rdG:Ver.2.0, and prepared the "Hospital Accreditation Data Book
2022".

Ⅱ．Surveyor Training Program
１．Surveyors
Surveyors visit and examine the hospitals at the request of JQ. There
were 748 people (285 medical practitioners, 278 nurses, 158 clerks, 17
pharmacists, 10 therapists, etc.) at the end of FY2022. The operating
ratio of surveyors were 77% in this fiscal year.
２．Training of Surveyors
19

A secondary selection (selection/training session) for applicants tobecome surveyors in FY2021 was conducted from July to October
2022, and those who passed the secondary selection werecommissioned as surveyors.
In addition, the recruitment and selection of surveyors for FY2022 wasconducted from December 2022 to February 2023.
３．Continuous training for surveyors
The following online workshops were held to train surveyors. In
addition, recorded videos of the surveyor study session were madeavailable for all surveyors to study.
Table 22 Continuing training for surveyors
Held times

Participants※

Surveyor study group

10

921

Follow-up workshop

1

31

Brush-up workshop

1

34

Leader workshop

1

23

1

275

Online workshop

Surveyor forum
Theme: Evaluation of hospitalfunctions - the past 25
years and the next 25
years

from

surveyor’s

perspective※The number of participants is the total number of participants.

４ ． Education for surveyors following revision of survey methods andstandards
We have produced a lecture video for the surveyor training on thehospital function evaluation 3rdG: Ver.3.0. We are preparing for thelaunch of 3rdG:Ver.3.0 from June 2023.

Ⅲ．Research and Development Project on Hospital Accreditation
１．Revision of hospital accreditation
20

Towards the start of operation of new accreditation criteria, thehospital function evaluation 3rdG: Ver.3.0,in June this year, somecomponents were developed through 6 trial surveys. The changes havemade by developing the new evaluation methods of thematic surveys ofoffice management areas, thematic surveys of drugs, medical safety
and infection control rounds, etc., by introducing the general hospital 3specific evaluation methods of medical record reviews and hospitalmanagement interviews into other types, and by reviewing of overall
adjustment of progress charts and survey materials, etc.
In addition, revisions were made to relevant systems, such as thesystem for preparing self-assessment survey forms.
２．Renewal of IAP Accreditation Standards
The renewal accreditation for IAP assessment standards accreditation
was carried out, and accreditation was granted. The results of all 65
assessment criteria were scored on a 4-point scale from 1-4, with a scoreof 4: 58 criteria; 3: 4 criteria; 2 (corresponding to a score of C in theassessment of hospital functionality): 3 criteria.
３．Investigation of web utilization in survey
We collected information on the use of the web for the purpose of
improving the quality and efficiency of evaluation in the survey.

21

【２】The Japan Obstetric Compensation System for Cerebral Palsy
The Japan Obstetric Compensation System entered its 14th year since its
start in January 2009, and has continued to operate stably. In fiscal 2022,
we will improve the quality of obstetric care by making greater use of thevaluable information obtained through this system, in addition to efforts suchas review and compensation, cause analysis, recurrence prevention, andefforts to promote compensation applications. In order to create conditions
for the future, we worked on the construction of the updated system and themaintenance of the database in parallel, and strove to strengthen the
management system as well.
As of the end of March 2023, 3,915 people were eligible for compensation,and 3,546 cases of cause analysis reports were created and sent. In March
2023, the 13th Recurrence Prevention Report was published.
１．Number of participating childbirth facilities
Table 1 shows the status of participation in the system of childbirthfacilities nationwide.
Table 1 Number of participating childbirth facilities (As of March 31, 2023)
Number of childbirth

Number of participating

facilities

childbirth facilities

3,145

3,142

Participation (%)
99.9※The number of childbirth facilities is counted by with the cooperation of the Japan
Association of Obstetricians and Gynecologists and the Japanese Midwives Association.

２．Compatible with the next system
The current obstetrics web system has built a network with about 3,200
childbirth facilities nationwide, and has been used for 14 years to manage
information on about 900,000 pregnant mothers annually and to also
manage compensation payments every year up to 20 years of age.
However, inefficient operational system is an issue as it is difficult to link
data with other small-scale systems and the renovation in the current
system requires high cost.
With the construction of the updated new system as an opportunity, we
will improve the productivity and quality related to the operation of thissystem, and make it possible to systematically aggregate and analyze thedata of this system. It will optimize and realize smooth operation.

３．Implementation of publicity and public relations, etc.
The deadline for applying for compensation under this system is until
22the child's 5th birthday. In 2022, the deadline for applying forcompensation was reached for children born in 2017, when the criteria forthe 2015 revision of the system were applied. For this reason, in order not
to miss the deadline of application for possible eligible children, efforts
have been made to publicize the promotion of compensation applications
with the cooperation of about 25 related academic societies andorganizations.
We will continue to make efforts to spread awareness widely incooperation with participating childbirth facilities, related academic
societies/groups, local governments, etc.
４．Implementation of examinations and compensation
Table 2 shows the total number of cases processed and its results since
the start of the system.
Table 2 Cumulative number of cases processed and its results since thestart of the system (as of the end of March 2023)
Results

Number of cases
processed

Eligible

5,174

3,915

Total

Not eligible

Cases In

Not eligible

Reapplication possible※

process

1,195

59

5

※ Although it is not eligible for compensation at this time, it will be reviewed again if the prescribed
requirements are met and the application is reapplied in the future.

(Reference) The number of cases processed by year of birth for children whose examinations
have been completed and its results
child's year of birth(As of March 31, 2023)
Results

Number of cases
processed

EligibleNot eligible

2009～2014 ※1

3,048

2,195

853

2015※2

475

376

99

※2

432

363

69

※2

426

340

86

2016
2017

※1 Compensation criteria
General examination 2,000g or more and 33 weeks or more/ Individual examination: 28 weeks ormore and prescribed requirements※2 Compensation criteria
General examination: 1,400g or more and 32 weeks or more/ Individual examination: 28 weeks ormore and prescribed requirements

５．Cause Analysis（１）Creation of cause analysis report
As of the end of March 2023, 3,546 cause analysis reports have beencreated and sent. Partly due to the impact of COVID-19, the average
23number of days from the notification of examination results to thesending of the cause analysis report is getting longer. Early in this fiscal
year, efforts were made to review the process management of report
preparation and to improve operational efficiency so that the number ofreport preparation days could be reduced to approximately one year.
The average number of days required to prepare reports sent in FY2022
was about 490 days which is reduced by about 70 days compared to
FY2021.
（２）Strengthening support for childbirth facilities
As a result of analyzing the causes of multiple cases at thesamechildbirth facility, in response to the "attachment (request)" requesting
further improvement when the same medical practice is repeatedly
severely evaluated from a medical point of view, the Japan Associationof Obstetricians and Gynecologists (hereinafter referred to as the"medical association") and the Japanese Midwives Association(hereinafter referred to as the "midwives association") are making
efforts to provide support if requested by the childbirth facility when
formulating and implementing improvement measures. In fiscal 2022,
we responded to 16 "attachment (request)" and provided support at the
medical association in response to one request from a childbirthfacilities. In order to improve the quality of obstetric care, we willcontinue to work with medical association and midwives association toincrease the effectiveness of responding to "attachment (request)".
（３）Publication and disclosure of cause analysis reports, etc.
Through the disclosure of the“cause analysis report summary” (noinformation that identifies individuals or childbirth facilities) on thewebsite of this system, and the “cause analysis report full text version(masking version)”to researchers, we are working to ensure thetransparency of this system and improve the quality of obstetric care.
As of the end of March 2023, 3,514 “summary versions” have been
published, and 13 “full-text versions (masking version)” have been
applied for use, with a total of 3,357 disclosures.
In addition, regarding the obstetrics system data, we are considering
adding data on the "causes of cerebral palsy onset" in the cause
analysis report with the aim of promoting the use of data, and aiming tostart accepting applications for use from 2024.
６． Recurrence prevention to improve the quality of obstetric care
（１）Creation of recurrence prevention report
In FY2022, the Recurrence Prevention Committee was held six times,
and the 13th Recurrence Prevention Report was published in March24

2023. In this report, from the perspective of preventing recurrence andimproving the quality of obstetric care, the theme of "uterotonic drugs"
was taken up and analyzed. Furthermore, as an analysis from a different
angle than before, we examined the "progress from the perspective of
the family."（２）Efforts to prevent recurrence and improve the quality of obstetric care
A leaflet was created based on the analysis results of the theme"intrauterine infection" taken up in the "12th Recurrence Prevention
Report". In addition, we contributed articles about efforts to prevent
recurrence in magazines for medical professionals, and disseminatedreports, leaflets, posters, etc. on recurrence prevention that we havepublished so far.
７．Status of Returned Premiums (Retained Earnings)
Under this system, if there is a surplus in insurance premiums after thenumber of persons eligible for compensation for each contract year has
been determined, the refunded premiums will be returned to JQ, which is
the operating organization, and will 8,000 yen per delivery, and fromJanuary 2022, 10,000 yen per delivery will be applied to the insurance
premium of this system.
Regarding the contracts from 2009 to 2016, the returned insurance
premiums have already been returned to JQ, and about 10.3 billion yen* ofthe returned insurance premiums for the 2017 contract have beenreturned. About 60.3 billion yen was appropriated to insurance premiumsby the end of March this year, and the remaining amount as of the end of
March this year was about 75.2 billion yen, which is being properly
managed by JQ.
In addition, following the December 2021 meeting of the "Review
Conference on Management and Investment of Investment Rates andReturned Premiums," which agreed to purchase 10-year Japanese
government bonds (¥5 billion each year for a total of ¥20 billion) over the
four-year period from 2022 to 2025, we purchased ¥5 billion of JGBs in
March of this year, following on from our purchases in 2022.
※ Approximately 10.3 billion yen in premiums returned for contracts in 2017
＝Contract premiums in 2017 about 23.2 billion yen－Minimum contract amount of
about 10.2 billion yen－Administrative expenses approx. 2.6 billion yen＋Interest
100 million yen

８．Status of insurance premiums, etc. during the period of insurance（１）Income premiums and claims (compensation)
Table 3 shows insurance premiums, etc. during the insurance period(one year from January to December).
25

Table 3 Status of insurance premiums, etc. as of the end of March2023 (unit: million yen)
Premium income
JanuaryDecember 2009
JanuaryDecember 2010
JanuaryDecember 2011
JanuaryDecember 2012
JanuaryDecember 2013
policy year

JanuaryDecember 2014
JanuaryDecember 2015
JanuaryDecember 2016
JanuaryDecember 2017
JanuaryDecember 2018
JanuaryDecember 2019
JanuaryDecember 2020
JanuaryDecember 2021
JanuaryDecember 2022

Insurance money(compensation money)

31,525

12,27032,383

11,16931,79910,38031,345

10,68031,061

10,41031,204

9,630

24,096

11,16023,866

10,74023,170

10,11022,4797,560

21,1685,670

20,8084,290

20,2281,860

17,076210

This system utilizes private insurance. For example, compensation forchildren born in 2018 is covered by premiums earned in 2018. Since thedeadline for applying for compensation is until the child's 5th birthday, thenumber of people eligible for compensation in 2018 and the total amountof compensation will not be finalized until 2024. Therefore, compensation
resources are managed by the insurance company for futurecompensation.
Even in contracts from 2018 onwards, if there is a surplus incompensation funds when the number of people eligible for26

compensation and the total amount of compensation are determined, theinsurance company will return the surplus to the operating organization.
Regarding premium income from 2015 onwards, due to systemrevisions in January 2015, the insurance premium per delivery waschanged from 30,000 yen to 24,000 yen. Due to the revision of thesystem in January 2022, the insurance premium per delivery has
decreased from 24,000 yen to 22,000 yen.
（２）Administrative expenses
Administrative expenses for 2022 are shown in Table 4.
Table 4 Changes in administrative expenses (unit: million yen)
JanuaryDivision

January-

Decemberyear-on-year2022
Operating969

organization(5.7％)

Insurance company

1,032

December
2021
988

△19

(5.0％)
1,200△168(6.1％)
Total(6.0％)

2,001

2,188

△187

(11.7％)
Premium income(11.0％)

17,076（100.0％）△3,152

20,228（100.0％）(The percentage in parentheses is the percentage of insurance premium income.)

Expenditure composition ratio in non-life insurance financial results(Total of 26 member companies of the General Insurance Association of Japan in FY2021)）

Administrative
expenses 43.3%
Insurance payout 56.7％

From "The General Insurance Association of Japan Fiscal Year 2021 Non-life Insurance Financial Statement Overview"

Expenditure composition ratio in compulsory automobile liability insurance

27(Fiscal 2021 non-life insurance and mutual aid total)

Administrative
expenses 26.5%

Insurance payout 73.5％

事務経費
26.5%

支払保険金
73.5%

From the "Outline of automobile insurance in 2022" material

Expenditure composition of obstetric compensation system (2022)

Administrative
expenses 12.4%
Insurance payout 87.6％(compensation)（３）Breakdown of Administrative Expenses of the Operating Organization
Table 5 shows the breakdown of administrative expenses for theoperating organization in 2022.

Table 5 Administrative expenses of the operating organization(unit: million yen)
JanuaryDecember
2022
Material
expenses707(4.1%)
Meeting expenses, travel
expenses, miscellaneous
honorariums, etc.（※1）
Printing and binding costs,
communicationtransportation costs, etc.
（※1）
（※2）
Office rent, etc.
28

109

yearonyear
+76

+87

JanuaryDecember
2021
631(3.2%)
22

50

△4

54

118

△9

127

Commission expenses

Labor
cost

Systemdevelopment/maintenancecosts
Advertisingexpenses,consumables expenses,
etc. （※2）
Salaries,
remuneration,etc., welfare expenses,
socialinsurance
premiums, etc. (*2)

Total

148

△11

159

177

+12

165

105

+1

104

262

△95

357

969

△19

988

(5.7%)
Premium income

17,076(5.0%)△3,152

20,228(The percentage in parentheses is the percentage of insurance premium income.)※1 Excludes expenses related to cause analysis and recurrence prevention, which
are eligible for subsidies.
※2 Excludes some costs eligible for subsidies.

29

【３】EBM and Clinical Guidelines
１．Evaluation and selection of Clinical Practice Guidelines(CPGs)（１）Evaluation and selection of CPGs
A．Search/collection and screening of CPGs
We exhaustively searched CPGs issued in Japan, collected 141 new
documents, and narrowed down CPGs to be evaluated by two-stage
screening.
B．Evaluation of CPGs
65 guidelines were evaluated based on the clinical practice guideline
evaluation tool "AGREE II" and "AGREE Reporting Checklist." In
addition, the evaluation was also conducted on 10 pre-publication
CPGs. Table 1 below shows the number of clinical guideline
evaluations, selections, and publications.
Table 1 Status of evaluation and selection of CPGs as of the end of
March 2023
number of ratings

65(post-publication)

Selected number

63

Number of posted

Number of

bibliographic

full-text

information

posted CPGs

65

66

10(pre-publication )（２）Feedback on clinical practice guideline evaluation results
For the 65 items that were evaluated after publication, we gave
feedback on 49 items after asking the creating organization whether
it was necessary or not. We also provided 10 pieces of feedback on
the 10 pre-publication evaluations.
（３）Information management for CPGs
We continuously checked the update status and managed so thatthe latest information was always posted on the website.
２．Publication of CPGs
（１）Publication of CPGs
In FY2022, the latest version of clinical guidelines was 131, of which
66 were posted in full text and 65 were only posted in bibliographic
information. In addition, the status of publication of CPGs on the Minds
website is shown in Table 2 below.
In 2022, 14 English-language clinical guidelines were newly posted, and 2
commentaries for the general public were newly posted. Tables 3 and 4
show the status of each release.
30

Table 2 Minds website publication status of clinical guidelines
As of the end of March 2023
Number
Kinds

Number of

FY2022

Number of

publications

number ofwithdrawals

at the end of

new(Outdated

March 2023

postedversion, etc.)

CPGs

Number of database registrations➢

The latest version of the number

766（65）168

103452（28）131103377（31）66

35

188（14）26

12170（17）39

22

19 （0）

1

1

75（-

65

68

37

0

registered in the databasePublication of the full text of thelatest version
Full text published in PDF

formatFull text published in link

formatFull text published in HTML

format

Unpublished text of the latest
version3）(Only bibliographic information
is disclosed)➢

Old version of database registration

314（37）

numberFigures in ( ) indicate increases/decreases in FY2022

Table 3. Publication status of English CPGs
Number of publications at the end
Number of newof March 2023
publications in
FY2022

Number of withdrawals(outdated, etc.)

14

44（8）

6

Figures in parentheses indicate increases/decreases in FY2022

Table 4 Status of information provision to the general public
Kinds

Academic guideline

Number of posted

FY2022

Number of

information at the

number of new

withdrawals

end of March 2023

posted(Outdated

information

version, etc.)

37（2）

2

0

8（0）

0

0

commentary
Guideline commentary for31

Minds version
Plain commentary for

46（0）

0

0

Minds version
Figures in parentheses indicate increases/decreases in FY2022（２）Constructing and improving the convenience of the Minds website
In addition to maintaining and operating the Minds website (including
selection of new vendors and migration), we reviewed the databasestructure by introducing a package-type CMS, made the website lighter,established a system for in-house production, and improved the searchfunction.
３．Support for development of CPGs
（１）CPGs development support according to CPGs development stage
A．Clinical practice guideline development manual
In order to confirm the dissemination status of the Minds Clinical
Practice Guideline Development Manual 2020, we continued toanalyze the number of views and downloads. In addition, a simplified
version of the flow chart (draft) was created to support thedevelopment of areas with little evidence.
B．Clinical practice guideline development seminar
Videos of clinical practice guideline development were introduced(4 academic societies, 15 creating groups).
C．CPGs development consultation deskIn response to 49 e-mail consultations, 9 consultation meetings
were held (number of participants: 96).
D．Clinical practice guideline development registration system (Clinicalpractice guideline registry)
10 new registrations were made (cumulative number ofregistrations: 32), and public comment support was provided for 2
cases.
（２）Clinical practice guideline development tool: patient/public
involvement support
Participated in the patient/citizen group meeting in preparation of the2022 version of CPGs for pancreatic cancer, and continued to provide
advice and information. In addition, we gave a lecture at a lecture
meeting sponsored by a patient group called “Allergypot”.
（３）Priority support for the development of CPGs
32

A questionnaire survey was conducted on trends and revisions of
CPGs for intractable disease areas, etc., and problems in intractabledisease areas were extracted and countermeasures were considered.
（４）Domestic Network of Clinical Practice Guideline Development
Group: Opinion Exchange Meeting
For the purpose of sharing information and exchanging opinions
regarding the development of CPGs, an opinion exchange meeting washeld for clinical practice guideline development organizations asfollows.
・September 17, 2022 (Saturday) 14:00-16:00 FY2022 No.1
Theme: "Ingenuity and challenges in CDGs development for intractablediseases"
4 lectures by the representative of guidelines development groups, 210participants・February 13, 2023 (Saturday) 14:00-16:30 FY2022 No.2
Theme: "Towards Desirable Management of Conflicts of Interest in
Clinical Practice Guideline Development"
4 lectures by the representative of guidelines development groups, 170participants（５）Network of overseas clinical practice guideline development groups
Participated in the 17th G-I-N (Guidelines International Network)
International Conference held from September 21st to September
24th, 2022 (online), and endeavored to understand international trends
in the creation, evaluation, and dissemination of CPGs.
４．Education for promotion of EBM and CPGs development
We have finalized and released the learning materials(introductorymaterials for beginners) for CPGs, which we started considering andcreating in FY2021. In addition, following the introductory teachingmaterials, we started planning and reviewing elementary teachingmaterials for clinical practice guideline creators.
５．Development of new evaluation and selection methods for guidelines for
medical treatment and individual techniques, etc.
Other than guidelines for medical treatment Medical information suchas clinical guidelines for COVID-19
issued by the Federation ofJapanese Medical Associations, the Ministry of Health, Labor and Welfare,and the National Institute of Infectious Diseases has been continuously
posted on the Minds website for dissemination.
６．Others
33

（１）Organizational collaboration
As a collaboration in the field of prevention and health promotion, an
event was co-hosted with AMED (Japan Agency for Medical Researchand Development) on November 21, 2022 to support the creation ofguidelines for the "Project for Establishment of Research andDevelopment Infrastructure for Social Implementation of Preventionand Health Promotion (Project for Establishment of Healthcare Society
Implementation Infrastructure)".
（２）Examination of future business operations
In FY2022, while focusing on the ICT project, which was the central
issue of this project, we began to consider the relationship withcopyright holders and publishers, and the path and measures toconnect the ICT project to new information provision services. As for
future issues, we will consider and consult on how to build a profit base,including the provision of paid information services, and how tocollaborate with related organizations. We will aim to study and prepare
more concretely. We will also proceed with concrete consideration ofbusiness collaboration within JQ.
（３）PR activities
A．Distribution of e-mail newsletters (distributed 52 times in total, 978,951
e-mails in total)
B．Posted on Facebook and Twitter (50 times on Facebook, 101 times on
Twitter)
C. Revision of PR leaflets, distribution to medical institutions, etc., andonline publication
7．Investigative research on electronic medical records that can refer to CPGs
（１）Standardization of clinical practice guideline data
We investigated the use of templates for clinical practice guideline
creation manuals and identified issues and requests. In addition, we
reviewed international practice guideline development and publication
formats, and proposed enhancements to clinical practice guideline
development manuals and templates.
（２）Developing and adjusting the ICT environment
A．Check and update PDF viewing in on-premises electronic medical
records
Through a viewing trial with a PDF viewer at two hospitals, examined
the update work, identified issues, and considered how to deal with them.
34

B．Confirmation of PDF viewing in cloud-based electronic medical records
and cooperation with clinical guidelines
We created a simulated electronic medical record (medical facility PC)
environment, and designed and implemented a clinical practice guideline
system (PDF).
C．Discussing the secondary use of CPGs
We exchanged opinions with publishers, identified issues, andconsidred countermeasures.
D．Consideration of new medical data linkage aiming at healthcare DX
We conducted a survey of organizations and policy trends toward
standardization of medical information and centralized management of
information.

35

【４】National Database of Medical Adverse Events
Ⅰ. Project to Collect Medical Near-Miss/Adverse Event Information
１．Overview
For the purpose of promoting the prevention of occurrence andrecurrence of medical adverse events, we collected, analyzed andprovided information on medical adverse events and near-miss incidents.
２．Project to collect, analyze, and provide medical adverse event information（１）Collection of medical adverse event information
We collected medical adverse event information from legally
mandated reporting institutions and voluntarily participating medical
institutions using a designated reporting screen on the web.
The number of reports of medical adverse event information
continued to exceed the number of the previous year or almost thesame number as the previous year, and there were 5,313 reports ofmedical adverse event information in 2022 (Table 1). In order to collectadditional information on cases, we requested information in writing (97cases). On-site visits at medical institutions could not be conducted dueto the epidemic of COVID-19 pandemic.
Table 1 Changes in the number of reports of medical adverse
event information
Numberofreports

Numberofreports

Numberofreports

2005

2006

2007

2008

2009

2010

1,265

1,451

1,445

1,563

2,064

2,703

2011

2012

2013

2014

2015

2016

2,799

2,882

3,049

3,194

3,654

3,882

2017

2018

2019

2020

2021

2022

4,095

4,565

4,532

4,802

5,243

5,313

（２）Analysis of medical adverse event information
Reported medical adverse event information is reviewed by a Expert
Analysis Team consisting of medical safety experts, etc., who holdmeetings once or twice a month on a regular basis. From among them,
we set the theme of the report to be published quarterly and analyzed
it.
36

（３）Provision of information
The collected and analyzed contents were widely provided to medical
facilities, related organizations, administrative agencies, the public, etc.
as the following information.
A．Quarterly Report/Annual Report
The 69th to 72nd Quarterly Reports and the 2021 Annual Report(including English version) have been compiled. Quarterly Reports
and Annual Reports were sent to participating medical institutions,related organizations, administrative agencies, etc., and posted on thewebsite of this project. In the report, the themes were set from thereported cases and analyzed (Table 2).
Table 2 List of analysis themes in the published Quarterly Report
ReportOverview

Analysis theme

69th

OthersEvents related to patient mix-up (2)70thOthersEvents related to patient mix-up (3)71stEventsEvents related to patient mix-up (4)Nursing care

Events where the bed-leaving sensor did not work due
to forgetting to turn on the power or incorrect usage

72th

OthersMedical equipment,

Events related to double checks
Events s related to the selection of syringe pump units

etc.

B．Medical Safety Information
In FY2022, 12 Medical Safety Information were compiled (Table 3).
Medical Safety Information is provided once a month, a total of 12
times, to participating medical institutions and approximately 6,000
medical institutions which request that information provided by fax,
and is also sent to related organizations and posted on the website ofthis project.
Table 3 Published medical safety information
No.
No.185
No.186
No.187
No.188
No.189No.190Overview
Medicaldevice, etc / Examination
Drugs/Examination

Title
Use of used endoscope on another patient

Failure to check blood test results before
administrating anticancer drugs
Summary
Medical safety information highlighted in Quarterly
Reports in 2021
Treatment/Procedure
Fitting of elastic stockings to patients witharteriosclerosis obliterans of the lower limbs
Nursing careBurns caused by a hot towel
Drainage tubes or other Selection of wrong connection for indwellingtubes/
bladder catheters37No.191
No.192
No.193
No.194
No.195
No.196

Treatment/Procedure
Drug
Medical device, etc /Nursing care
Drug
Medical device, etc.
OthersSummary

Local injection of high-concentration adrenaline
due to container mix-up
Pressure ulcers related to medical devices
Wrong drug administration route(1st follow-up
report)to reconnect the ventilator circuit due to use of
test lungExamination and treatment of wrong patient due tolack of verification
Medical Safety Information released in 2022

C． Database of eventsIn FY 2022, the reports of medical adverse event information
submitted between October 2021 and September 2022 were
published on the “event search”system of the website afteranonymizing and reflecting additional information. As of the end of
March 2023, 49,381 reports of medical adverse event information canbe searched.
３ ． Project to collect, analyze, and provide medical near-miss event
information（１）Collection of medical near-miss events
Similar to medical adverse event information, medical near-missevent information was collected using a dedicated reporting screen on
the web. In 2021, there were reports of 1,018,480 information on thenumber of occurrences and 31,857 medical near-miss
event
information.
（２）Analysis of near-miss event
From January to December 2022, we set the theme of "Events inwhich an error was discovered before implementaion due to theeffective double-checking", and the events were collected andanalyzed by the Expert Analysis Group along with medical adverse
event information.
（３）Provision of information
As with medical adverse event information, the collected medical
near-miss events were provided on the website, in quarterly reports andannual reports, and are encouraged to be widely used. In FY 2022, someof the medical near-miss event information reported between October
2021 and September 2022 was anonymized and published on the“Event Search” system of the website. As of the end of March 2023,
86,447 medical near-miss events can be searched.
38

４．Promoting utilization of the website
In order to promote the utilization of project deliverables, efforts weremade to further publicize the contents and functions of the website
through introductions in reports and lectures.
５．Consideration of report items
As more than 15 years have passed since the start of the project, wehave started to consider the possibility of revising the reporting items of
the reporting system from FY2020 in order to improve the reporting
environment for participating medical institutions in response to thecurrent environment surrounding medical care. In FY2022, we continued
to consider report items and completed the revision.
６．Workshops and lectures on medical safety（１）Holding workshops
For medical institutions participating in this project, we held Webformat lectures twice to promote the use of this project's reports andMedical Safety Information, and to improve the quality of reporting of
medical adverse event information and near-miss information. (Table 4).
Table 4 Outline of the workshop
Content
1st

Date

RCA Workshop

Feb

18,

Number of participants
358 people

2023

2nd

WorkshopMar 5,“Efforts for medical safety from2023

the viewpoint of cooperation
between medical institutions andpharmacies”※

Participating medical
institutions: 128 people
Participating pharmacies:
416 people※Jointly held by Project to Collect Medical Near-Miss/Adverse Event Information
and Project to Collect and Analyze Pharmaceutical Near-Miss Event
Information.

（２）Response to request for lectures
In response to requests from medical institutions and relatedorganizations, we gave lectures mainly in a web format in which we
explained the contents of the deliverables of this project and called forparticipation and reporting on this project.
７ ． Holding of Steering Committee and Comprehensive Evaluation
Subcommittee
The Steering Committee meetings were held twice a year on the web
to deliberate on the operation of this project. In addition, the39Comprehensive Evaluation Panel met four times a year on the web toreview and support the preparation of reports, Medical Safety
Information, etc. from a technical and professional point of view.

Ⅱ . Project to Collect and Analyze Dental Near-Miss Event
Information
１．Development of reporting environment
A system for collecting, analyzing, and providing near-miss event that
occurred in dental clinics was constructed.
２．Consideration of implementation system
The Comprehensive Evaluation Panel consisting of dentists, dental
hygienists, dental technicians, etc. was held once to consider how topublicize the project to dental clinics and the deliverables of the project inorder to start collecting case studies in FY2023

Ⅲ. Project to Collect and Analyze Pharmaceutical Near-Miss Event
Information
１．Overview
For the purpose of further promotion of medical safety measures,
events were collected from pharmacies participating in the project,
analyzed, and provided.
２．Collection, analysis and provision of events（１）Registration of pharmacies wishing to participate
The registration work of pharmacies wishing to participate in thisproject proceeded smoothly. The number of participating pharmacies atthe end of 2022 was 45,290, and as of the end of March 2023, it
became 45,593.
（２）Collection of events
The number of reported events in 2022 was 120,247 (Table 5).
Table 5 Changes in the number of participating pharmacies and thenumber of reports
2009
Number ofparticipating
1,774
pharmacies
Number of
1,460
reports
Number of

2014
8,244

2010

2011

2012

2013

3,449

6,037

7,225

7,747

12,904

8,082

7,166

5,820

2015
8,577

2016
8,700

2017
11,4002018
33,08340

participating
pharmacies
Number ofreports
Number ofparticipating
pharmacies
Number ofreports

5,399

4,779

4,939

6,084

2019

2020

2021

2022

38,67740,957

43,16645,290144,848

129,163

127,937

120,247

79,973（３）Analysis and provision of information
The Expert Analysis Group meetings, consisting of pharmacists andothers familiar with pharmacy operations and involved in medical safety,
were held twice a year to review reported events and provide the following
information.
A．Periodic Report/Annual Report
In FY2022, the 27th and 28th Periodic Reports and the 2021 Annual
Report were prepared and published. In the reports, themes were set
from among various cases and examined by the members of the Expert
Analysis Group (Table 6). Periodic Reports and Annual Reports weresent to related organizations, administrative agencies, etc., and postedon the website of this project.
Table 6 Analysis themes taken up in the report
ReportAnalysis theme

27th

Events related to contraindications for co-administration
Events related to continuation of drugs after discharge

28th

Events related to injectable antidiabetic drug
Events related to omissions in prescription of oral
medicines

B．Events to share
We selected events that were deemed necessary to be sharedespecially widely as useful information for medical safety measures,and created "events to be shared" with the points of the cases. In
FY2022, a total of 35 cases were announced.
C．Learn from events
For each of the themes analyzed in the periodic reports, we createdand published a summary of key points from representative events andsimilar events that have been reported so far under the title "Learningfrom Events."

41

D．Database of events
We anonymized the reported events and published them on theevent search system on our website. As of the end of March 2023, itis possible to search 305,029 cases in the old format that werereported before the March 2020 reporting system upgrade, and369,254 cases in the new format that were reported after thereporting system upgrade.
３．Utilization of homepage
In order to promote the utilization of the deliverables of this project,efforts were made to further publicize the contents and functions of thewebsite through introductions in reports, workshops and lectures.
４．Workshops and lectures on medical safety（１）Holding workshops
One web-based lecture was held for pharmacies participating in the
project, with the aim of promoting the use of the information provided
and improving the quality of reporting by explaining the results of the
project and how to analyze events (Table 7).
Table 7 Outline of the workshop
Content

Openingday

2022 Workshop
viewpoint

Mar 5,

Medical Adverse Event Information

2023

Collection Project
Participating medical institutions:“Efforts for medical safety fromthe

Number of participants

cooperation

Pharmaceutical Near-Miss Eventbetween medical institutions andInformation Collection and Analysis

pharmacies”

of

128 people

Project※

Participating pharmacies: 416
people※ Jointly held byProject to Collect Medical Near-Miss/Adverse Event

Information and Project to Collect and Analyze Pharmaceutical Near-Miss
Event Information（２）Response to request for lectures
We responded to requests for web-format lectures at seminars andworkshops hosted by pharmacies, related organizations, administrative
agencies, etc., and worked to disseminate the significance of thisproject and return the results.
５．Holding of Steering Committee and Comprehensive Evaluation Panel
42

Steering committee meetings were held twice a year on the web todeliberate on the operation of this project. In addition, the Comprehensive
Evaluation Panel met twice a year on the web to review and support the
preparation of reports and annual reports from a technical andprofessional point of view.

43【５】Patient Safety Promotion
１．Overview
The Council for the Patient Safety Promotion (PSP) in accredited
hospitals was established by volunteers from hospitals that have obtained
accreditation for hospital accreditation, with the aim of promoting patient
safety, and has been operating as a project since Apr. 2003. The Council
contributes to the promotion of patient safety in hospitals throughout
Japan by establishing subcommittees to address urgent issues related topatient safety, conducting various studies, holding seminars, andpublishing the Journal of Patient Safety Promotion.
２．Member Hospitals and Annual fees
There were 1,307 hospitals that were members of the council(admission rate: 64.9% of total number of accredited hospitals in 2013).
The annual membership fee was 60,000 yen.
３．Holding Committees, Subcommittees, etc.
In FY 2022, in addition to holding two steering committee meetings, weestablished five subcommittees and two study groups to analyze causes
and consider effective accident prevention measures according to issues.
We continued to hold mainly online events in consideration of thesituation of the COVID-19 in FY2022 as in FY 2021. However, some inperson meetings (group meetings) were also held.
Table 1 Status of holding subcommittees
Subcommittee Name
Held
Times
Drug Safety Expert Group
3

Clinical examination/
Treatment/ Surgery Safety
Expert Group

3

Education Program Expert
Group

3

44

Activities
A expert group discussed theannual theme of "safe andeffective drug administration
process",
and
held
a
questionnaire survey and awebinar. In addition, thematerials
collected
frommemberhospitals
werepublished on the PSP website.
Continuing from 2020, group
work seminars were held under
the theme of "Focusing on
Perioperative 'Handoff'".
- Support project for medialsafetymanagerhandling

Facility/Environment/Equipment
Safety Expert Group

3

Journal Planning Expert Group

4

Central Venous Catheterization(CVC) Study Group0

SuicidePrevention
andPostvention in Hospitals Study
Group

1

everything by myself.
- Positive approach workshop
was held, which has been on
trial since FY2019, to decipher
incident cases with positive
thinking, and discuss reactions
and impacts on subsequent
responses and feedback.
Collaborative
practice
workshop was held in a web
format because it was notpossible to hold a group typeunder the COVID-19 pandemic.
We collected incidents andaccidents related to facilities,
environments, and equipment
and added them to the PSP
website. Cases that should beshared in particular were
picked up at seminars, andspecialists
inhospitalarchitecture and equipment
manufacturers were involved in
discussions
aimed
atpreventing recurrence.
We published a regular issue ofthe Patient Safety Promotion
Journal four times a year andtwo separate volumes.
The CVC workshop did not holda review meeting because it
was difficult to continue thehands-on seminar due to the
COVID-19 pandemic.
In addition to sorting out theresults of the workshop heldcollectively
while
takingmeasures against infection, we
also discussed how to hold thenext workshop.

４．Holding Seminars
Based on the deliberations of the expert groups and study groups, we45

returned the results of our activities to the members through seminars.
Table 2 Status of Holding Seminars
Holding
FormatOnline

Held
Times
2

Clinical Examination/ Treatment/
Surgery Safety Seminar(Workshop style)

Online2

Facility/ Environment/ Equipment
Safety Seminar(Symposium style/ Workshop style)

Online

3

432
272
30
Total 734

Education Program Seminar- Support project for medical
safetymanagerhandling
everything by myself- Positive approach workshop- Collaborative practice workshop(Workshop Style)

Online
2

24
19

1
1

19
30
Total 92

Seminar Title
Drug Safety Seminar(Symposium style)

CVC Workshop
Workshop for Suicide Prevention andPostvention in hospitals(Workshop Style)

InPersonParticipants359
313
Total 672
45
26
Total 7101

18

５．Regional and General Forums
Regional forums, which are planned by the lead hospitals and takeadvantage of the characteristics of the region, were held in a online
method last year but not this year.
The annual general forum, which also served as a debriefing session on
the activities of the expert group, was held in a online method.
Table 3 Status of Patient Safety Promotion General Forum
Holding
Date
Theme
MethodWhat is Good Judgment and Decision
Mar. 4
OnlineMaking in Clinical Practice?

Participa
nts
568

６．Video Distribution" Educational videos on patient safety" for in-hospital training and46

individual study, and later delivery of webinars were made available on the
PSP website.
Table 4 List of Educational Videos for FY 2021
(Release period: Oct. 1, 2021 to Sep. 30, 2022)
Release
Date

Title

* NumberofCompleted Views(1 year)

LecturerOct.
1, Sarcopenia frailty that healthcare Yoshihiro
2021
professionals should know
Yoshimura
Ditto
Practical Responses to Delirium
Asao Ogawa
Ditto
Ditto
Ditto

Rethinking
disastercountermeasures in hospitals
Use of FMEA techniques inpatient safety
Basic knowledge of electricalequipment that medical personnel
should know

YasushiNakajima
Kenji Tanaka

4,462
3,763
2,285
1,386

Haruki Sumi
605

Table 5 List of Educational Videos for FY 2022
(Release period: Oct. 1, 2022 to Sep. 30, 2023)

Release
Date

Title

Lecturer

Oct. 1,2022
Ditto* NumberofCompletedViews(as of theend of Mar.)

What is psychological safety Ryosuke
5,012
required in the medical field?
Ishii
Basic knowledge of DNAR Satoshi
2,018
necessary for medical safety
Gandou
Ditto
Basics of iatrogenic sarcopenia
Yoshihiro
371
and multidisciplinary support
Yoshimura
Ditto
Basic
knowledgeof
air Akifumi
conditioning and ventilation in Suzumura
277
hospital buildings
Nov. 14,
Utilizationofdrugrisk Masahiro
2022
management plans for medical Hayashi
96
safety*Completed Views: The number of times the video was viewed to the end
47

Table 6 List of Online Seminars
Date of
Title
Online Seminar
1stJul. 11
Facility/Environment/Equipment
Safety Seminar

Publication Period
of Recorded video
6 months

Oct. 15

1st Drug Safety Seminar

6 months

Oct. 26

2nd
Facility/Environment/Equipment
Safety Seminar

6 months

Feb. 3

2nd Drug Safety Seminar

6 monthsMar. 4General Forum
Safety Promotion

6 months

48

forPatient

【６】Education and Training for Health Care Professionals
１．Overview
In order to realize continuous quality improvement activities to improve
the quality of medical care, it is essential that individuals affiliated withhospitals acquire systematic knowledge and skills related to medical
quality and safety and put them into practice. In addition to providing
support to the entire organization in hospital accreditation, we provide
appropriate educational programs to individuals involved in medical care,and conduct “individual education” so that they can fully play their roles intheir respective environments and positions.
Figure 1 Overview of Supporting Continuous Learning and
Maintaining/Improving Quality of Healthcare (JQ-MAP)

２．Holding Status of Committees and Subcommittees
A business management committee was held to discuss the policies of
the Education and training. In addition, a online subcommittee was held todiscuss the certification and renewal of Healthcare Mediators and medical
quality managers.

Table 1 Status of Meetings of Committees and Subcommittees
Committee
Holding
Held Times
Date/ Subcommittee Name
Method49

Education andTraining Steering
Committee
Accreditation/Renewal
Examination
Subcommittee

Online2

May. 19
Feb. 17

Online2

Sep. 12Mar. 13

３．Seminar Status（１）Healthcare Mediator Training Seminar
Based on the concept of "medical conflict management," which aims
to solve various problems that arise between patients, families, medical
institutions, and staff in a collaborative and flexible manner throughdialogue, the Council for the Patient Safety Promotion in accredited
hospitals has developed a training program. Since 2004, it has been
held under the name of "Medical Conflict Management Seminar," andsince 2013, it has been co-sponsored by the Japan Medical
Association and changed its name to the "Healthcare Mediator
Training Seminar."
Currently, we are co-sponsoring a program with the Japan Medical
Association for a Total of about 20 hours, which combines lectures onbasic knowledge and work-based training to learn dialogue skills
through role-plays (The program has been approved as a program thatmeets the requirements for the additional patient support system for
medical reimbursement).
Previously, all programs of this seminar were held in-person(gathering at the venue), but due to the impact of the COVID-19
pandemic, the program has been changed to an online program since
FY 2021. Two types of programs were implemented: the entire
program was consisteted of held the lecture part and the practice partof the program was held in-person (at the venue). Participation types
can be selected according to the learning environment and needs ofstudents.
In 2022, it was held in two formats and 379 people graduated it.
Table 2 Healthcare Mediator Training Seminar Format
Type
Holding Method
Lecture Part
Video Viewing
400 minutes of+ In-Person
video viewinga(Meeting at the[1 month]
Venue)
Video Viewing
400 minutes ofb+ Online
video viewing[1 month]50

Practice Part
Meeting(in-person)
820 minutes[2 days]
Online 840
minutes[2.5 days]

Table 3 Status of FY 2022 Healthcare Mediator Training Seminar
Type
a

b

Times

Title

Holding Method

1

InPerson82

Video

Inperson

1

Web 5

Video

Online

2

Web 6

Video

Online

3

Web 7

Video

Online

4

Web 8

Video

Online

Date

Gradu
ates

Jul. 30, 31

23Jun. 18, 19,
Jul. 3Oct. 22, 23,
Nov. 13
Dec. 3, 4, 18
Feb. 11, 12,Mar. 587
88
92
89
Total 379

（２）Medical Quality Manager Training Seminar
Since 2012, we have continued to hold seminars to train “Medical
Quality Managers” who play a central role in continuous quality
improvement activities within the hospital.
This seminar aims to acquire basic knowledge about the quality of
medical care, information analysis skills, management skills, etc., andincorporates a lot of group work by multi-professionals to lead topractical activities.
In 2022, in order to improve the bias in the number of applicants dueto the timing of the event, which has been an issue so far, we set thedates centered on the second half of the fiscal year, and reduce thenumber of times from 3 to 2 times. We also increased the capacity andrecruited. As a result, 156 students applied for the course, exceeding
the annual number of 150 students planned at the beginning of the
fiscal year, and a Total of 151 students graduated the course.

Table 4 Status of FY2022 Medical Quality Manager Training Seminar
Holding Format / DateVideo
OnlineOnlineTimes
Graduates[0.5[1 day][3 days]months]
1st semester
2nd semester
1
Aug
Sep 2
Oct 6, 7, 21
77
2
Nov
Dec 2
Jan 12, 13, 27
74
Total 151

51

（３）Medical Safety Master Training
In order to deepen their knowledge of medical safety, the seminars
are held mainly for managers and full-time employees of medical
safety departments in hospitals, with the aim of further improving thequality of medical safety management practices and education within
hospitals.
In 2022, the Day 1 and Day 2 programs were held online once and 39
people graduated them.
Table 5 Status of FY 2022 Medical Safety Master Training
Times
Holding
Date
Graduates
Method1
OnlineFeb. 18, Mar. 25
39（４）JQ Medical Safety Manager Training
In order to develop human resources who can contribute to thepromotion of medical quality and safety through medical safety
management work, e-learning-based training has been implemented
since FY2022.
This seminar consists of an e-learning program (about 35 hours) andparticipatory training (about 6 hours, 1 day) conducted online .
In FY2022, participatory training was held four times a year, and 343
people graduated it (Table 6).
Table 6
Times
1
2
3
4

Status of FY2022 JQ Medical Safety Manager Training
Holding Method
Date
Graduates
e-learning
OnlineSep 1487
e-learning
OnlineOct 1979
e-learning
OnlineJan 1889e-learning
OnlineFeb 8
88
Total 343

In addition, with the aim of disseminating the e-learning program ofthis training nationwide as a standard program, we cooperate with eachorganization that wishes to use it and support 35 hours of learning for
medical safety manager, and we collaborated with three organizationsin 2022.
（５）Follow-up Seminars for Graduates
So far, as a place for those who have graduated the basic program tocontinue learning, follow-up seminars have been held for those whohave graduated the Healthcare Mediator training seminar and the
medical quality manager training seminar.
52

In FY 2022, 11 seminars were held online, with 789 participants.
Table 7 Status of FY 2022 Follow-up Seminars(CM: Graduates of Healthcare Mediator Training Seminar,
QM: Graduates of Medical Quality Manager Training Seminar)
Holding
Theme
Times
TargetDate
FormatSupporting staff involved in
medical accidents
Sharing case studies for Medical
Quality Manager (1)Participants

1

OnlineCM2OnlineQM

3OnlineCM,
QM

4OnlineCM

5

OnlineCM

6

OnlineCM

7

OnlineCM8

OnlineQM

9OnlineCM

Models of Healthcare Mediation

Dec 19152

Feb 1027

Leadership seminar

Jul 4

73

Jul 7

59

Aug 18168

Cooperation between patient
Oct 2
consultation and medical safety
Coordination between patient
consultation and medical safety Oct 2(half day)
Sharing
casestudiesfor
Oct 29Healthcare Mediator
Response from ethical aspects in
Nov 19patient consultation
Sharing case studies for Medical
Dec 16
Quality Manager (2)10OnlineQM

Thinking about visualization andimprovement measures for the
blood collection test work
process

11

Online

QM

Learning basic data analytics

64
6
112
61
59

Aug 22 8
Oct 7
Total 11 times 789

４．Operation Status of the Certification/ Renewal System
For those who have graduated the Healthcare Mediator Training
Seminar and the Medical Quality Manager Training Seminar, we haveestablished and operated a certification and renewal system to support
continuous learning and practice of activities.
（１）Certification and Renewal of the Healthcare Mediators

53

Since 2017, the Healthcare Mediator Training Seminar has certified
those who have graduated the entire course as the “Healthcare
Mediators”. The certificate holders are required to attend a follow-up
seminar every three years to renew their certification.
In FY 2022, there were 379 new certifications and 61 renewals.
（２）Certification and Renewal of the Medical Quality Manager
Since 2017, the Medical Quality Manager Training Seminar has beencertifying those who have implemented and promoted quality
improvement activities within the hospital as medical quality managers
among those who have graduated the course and wish to be certified.
Certificate holders will renew their certifications every three years,
meeting the requirements such as implementing and promoting quality
improvement activities within the hospital and attending follow-up
seminars.
In FY 2022, 42 people were newly certified.
５．Special Functioning Hospital Administrator Training
Special Functioning Hospital Administrator Training, which wascommissioned by the Ministry of Health, Labor and Welfare since2017, was conducted for administrators, medical safety managers,
drug safety managers, and medical device safety managers of special
functioning hospitals.
The medical radiation safety manager made it possible to attend thecourse if requested. In FY 2023, two types of training were conductedaccording to the training history.
The initial course was conducted for those who were taking thespecial functioning hospital administrator training held by JQ for the
first time, and a Total of 55 people from 43 hospitals attended.
Continuous course was conducted for those who had attended thespecial functioning hospital administrator training conducted by JQ atleast once in the past from 2017 to 2021, and a Total of 308 people
from 86 hospitals participated.
For both initial and continuous courses, lectures were recorded anddistributed on-demand via e-learning, and the viewing status of each
student was checked. In addition, Q&A and Group work for each lecture
were held online on each schedule in the table below.
Table 8FY2022 Initial Course for Special Functioning Hospital
Administrators
Graduates
Times
Holding Method
Date(Hospitals)
541

OnlineNov 302

OnlineDec 23

32
(27)
23
(20)
Total 55
(43 )<Contents>･[Video] Matters to be done by administrators of special functioning hospitals･[Video] Management of medical quality and safety･[Video] Basic abilities and attitudes required of administrators, etc.
･[Video] Organizational management and governance in special functioning
hospitals･[Video] Basic abilities and attitudes required of administrators･[Video] Governance necessary for hospital administrators･[Video] Operation of the Medical Near-miss/Adverse Event Investigation
System･[Video] About the Boundary between Medical Care and Research- From the Viewpoint of Medical Ethics and Insurance Medical Care ･[Video] Cyber Security Measures for Hospitals 2022･[Video] Medical Accidents Investigation System･[Group Work] Case method teaching･[Group Work] Effective Utilization of External Evaluation
Table 9 FY2022 Continuous Course for Administratorsof Special Functioning Hospitals
Holding
Graduates
Times
Date
Method(Hospitals)
45
1
OnlineNov 11(40)
50
2OnlineNov 21(38)
47
3
Online
Dec 7
(35)
55
4
OnlineJan 16(38)
56
5
Online
Feb 2
(46)
55
6
OnlineFeb 20(34)
Total 308
(86)
<Contents>･[Video] Creating a hospital that utilizes the nursing department organization･[Video] Operation of the Medical Near-miss/Adverse Event Investigation
55

System･[Video] About the Boundary between Medical Treatment and Research From the Viewpoint of Medical Ethics and Insurance Medical
Treatment ･[Video] Cyber Security Measures for Medical Institutions 2022･[Video] Medical Accidents Investigation System･[Group Work] Creating a strong hospital (organization) that utilizes multiple
professions and multiple departments56

【７】Other Projects to Achieve the Purpose of JQs with Japanese
Government
１. Improvement Project for Enhancing Health Care Quality(Quality Indicators)（１）Overview
This project was started in 2019 as a project subsidized by the
Ministry of Health, Labor and Welfare, aiming to develop a system for
improving the quality of health care through sharing and dissemination
specific efforts to improve the quality of health care, developing corehuman resources who will be responsible for activities to improve thequality of health care, standardizing health care quality indicators, etc.,
and supporting the evaluation and analysis of health care quality
indicators, etc.
（２）Organizational structure for implementing the project
A．Operation of the Steering Committee (Council for improving the qualityof health care)
Four conferences were held by hospital groups that have beenworking to improve the quality of health care, and they discussed the
project policies, the status of the model project " Health care Quality
Visualization Campaign (hereinafter referred to as the "Visualization
Campaign"), and consideration of each subcommittee andstandardization and publication of health care quality indicators.
B．Operation of subcommittees
We operated two subcommittees, the QI utilization support
subcommittee and the QI standardization subcommittee.
The QI utilization support subcommittee was held four times, andexamined and implemented a follow-up survey of pilot project
cooperating hospitals and a success factor analysis using collectedcases. In the success factor analysis using collected case studies,interview surveys were conducted at two hospitals, and a report "Pointsof Quality Improvement Activities Learned from Case Studies" wascreated to introduce and share the efforts of quality improvement
activities at each facility.
The QI Standardization subcommittee was held 7 times to plan andoperate the selection of health care quality indicators (9 indicators intotal from medical safety, infection control, and care areas) to be
applied to the visualization campaign, response to inquiries, andconsideration of feedback methods. In addition, inter-comparison
between existing QI project participating hospitals and visualization ofpatient-centered care were examined.
57

C．Operation of consortium for quality health care (QI Consortium)
The Consortium Special Event 2022 for quality health care
improvement was held online. A keynote speech and round-tablediscussion were held under the theme of "Visualize and improve thequality of health care -Let's work nationwide! Visualize the quality ofhealth care using indicators-", and 1,090 people participated, exceeding
the number of last year.
D．Management of the secretariat
A secretariat is set up in JQ, which operated the council andsubcommittees, planed and operated the QI consortium, implemented
the visualization campaign, communicated and coordinated with thesecretariat of cooperating organizations, and provided information via
official website of this project (https://jq-qiconf.jcqhc.or.jp/).
（３）Project Achievement
A．Sharing and dissemination of specific efforts to improve the quality ofhealth care
625 hospitals nationwide participated, including 229 hospitals that did
not participate in QI projects run by cooperating organizations that
implemented visualization campaign. As a result, we were able toconduct a nationwide benchmark evaluation using a common index.
In addition, we conducted an interview survey on the details of quality
improvement activities at two hospitals selected from the "Collection of
Improvement Cases Utilizing Health care Quality Indicators" posted on
the official website of this project. A private hospital (Gunma Prefecture,care mix type, 189 beds) and B municipal hospital (Shiga Prefecture,acute phase type, 438 beds) were selected as targets. At both hospitals,
quality improvement activities have taken root as part of theirorganizational culture, and content was created to organize and sharethem.
B．Training of core human resources responsible for activities to improve
the quality of health care
In the visualization campaign undertaken this fiscal year, the policy is
to place emphasis on continuous measurement work and not toemphasize the implementation of the PDCA cycle. Therefore, whencontacting the visualization campaign cooperating hospitals(hereinafter referred to as "project cooperating hospitals"), we
introduced the "Quality Improvement Toolkit" that has already beencreated and helped to improve the skills of those who are motivated to
implement the PDCA cycle. In addition, we asked the project58

cooperating hospitals to self-evaluate their competencies (ability
required to implement quality improvement activities) and collected theresults.
C．Standardization of health care quality indicators, etc.
The council continues to discuss the "how to standardize andpublicize health care quality indicators." This year, through the operationof a visualization campaign, we worked on the standardization of quality
indicators that are required to be measured nationwide. From among thequality indicators adopted by cooperating organizations, 9 indicators
were selected in accordance with the Basic Guide to Health care Quality
Indicators, and hospitals nationwide worked together to measure themin a visualization campaign. The 9 indicators consists of 3 medical safety
indicators (tumbles/falls (number of cases), tumbles/falls (3b or higher),pulmonary embolism prevention (risk level “medium” or higher)), 3
infection control indicators (2 sets of blood cultures, wide area Bacterial
culture when using antibiotics, prophylactic administration of antibiotics),
and 3 indicators of care (occurrence of pressure ulcers <d2 or more>,nutritional care during early hospitalization (65 years or older), andphysical restraints). In the future, we plan to verify the 9 indicators wedealt with based on the measurement results, and propose them tosociety as standard quality indicators for medical care after
deliberations by subcommittees and councils.
D．Support for evaluation and analysis of health care quality indicators,
etc.
We supported the measurement work and visualization of
measurement results through distribution of measurement procedure
manuals (documents describing the significance of indicators,
definitions of numerators and denominators, measurement procedures,etc.) and measurement worksheets (Excel sheets for recording andsubmitting measured values) to project cooperating hospitals. Not only
that, by responding to inquiries from project cooperating hospitals, we
supported the on-site personnel in conducting appropriate
measurement work and interpreting the results. In addition, whenproviding feedback on the measurement results, we distributed
supplementary explanatory materials to help them deeply interpret themeasurement results.

Japan Hospital Association

59

Japan Association of Medical and Care Facilities
Japan Municipal Hospitals Association
All Japan Hospital Association
Japan Medical Association
Japanese Nursing Association
Social Welfare Organization Saiseikai Imperial Gift Foundation
Japan Federation of Democratic Medical Institutions
National Hospital Organization
Japan Community Health Care Organization
Japan Organization of Occupational Health and Safety
Japanese Red Cross Society

Table 1 Improvement project for enhancing health care quality
List of cooperating organizations(as of March 2023)

Table 2 Examination results for Council for Improving Health care Quality
11th

Jun 27

Policy for this fiscal year, status of model

projects, status of deliberations bysubcommittees, ideal way for standardizationand publication
12th

Sep 29Situation of model projects, consideration of

each subcommittee, ideal way ofstandardization and publication
13th

Dec 1

Measures to disseminate quality indicators



nationwide, standardization and publication
14th

Mar 17, 2023

Status of model projects, consideration of eachsubcommittee, FY2022 business report,
FY2023 business plan proposal

Table 3 Examination results for QI Utilization Support Subcommittee
11th

Jun 13Business plan for this fiscal year,
dissemination and promotion of variousdeliverables, success factor analysis

12th

Aug 9



Dissemination and promotion of quality
indicators utilization, follow-up to pilot activity
cooperating hospitals

13th

Oct 4



Status of model projects, how to proceed withresearch, analysis of success factors, pilot
activity follow-up

interview
surveyJanuary 18, 2023

Gunma Prefecture, 100-200 beds, care mix
type

60

interview

Jan 30

Shiga Prefecture, 200-500 beds, acute stage

Feb 15Future policy, interview survey, follow-up

survey14thquestionnaire, status of model business

Table 4 Examination results for QI Standardization Subcommittee
18th

May 19This year's policies, about model projects,
Selection of indicators

19th

Jun 16



Selection of indicators, operation of
measurement and feedback

20th

Jul 7



Status of model projects, selection ofindicators, patient-centered care

21st

Sep 9



Status of model projects, standardization ofquality indicators, patient-centered care

22nd

Oct 20

Status of model projects, standardization ofquality indicators, mutual comparison, patientcentered care

23rd

Nov 18

Status of model projects, standardization ofquality indicators, mutual comparison, patientcentered care

24th

Jan 27, 2023



Status of model projects, standardization ofquality indicators, mutual comparison, patientcentered care

Table 5 Overview of Consortium Special Project 2022 for Improving Health care
Quality
Date and time

July 30, 2022 (Sat) 13:30-15:00

Holding method

Online (Live streaming on YouTube)

Theme

Visualize the quality of health care and improve it - Let's
work on it nationwide! Visualization of health care quality
using indicators

Participant

1,090 people (maximum number of simultaneous viewers)

Program

Guest greeting

Explanation of purpose "To visualize and improve thequality of health care"

Lecture "Aiming to improve the quality of healthcare"Three-way discussion "Importance of visualization for
quality improvement"

Table 6 Deliverables (newly created or updated)
1

Healthcare

QualityAreportsummarizingthemeasurement

valuesVisualization Campaign

submitted by the hospitals that cooperated with theAggregation

project to visualize the quality of health care, andResults61

Reportdescribing the overall distribution and basic statistics.
The following types were created and distributed.
○ 1st feedback(Period covered: October 1, 2021 to March 31, 2022)
Feedback data materials [Preliminary version]
Aggregation result report [summary version]
Aggregation result report [detailed version]
Aggregation result report Explanatory material○ 2nd feedback(Period covered: October 1, 2021 to September 30,
2022)


2

3

Aggregation Result report

Key Points for Quality

A report based on interview surveys conducted at two of

Improvement Activities

theLearned from Examples

improvement case studies collected last year.

Healthcare quality index

A website where you can search for quality indicators

search site (latest index

operated by hospital organizations. Updated to the latest

update)data.

hospitals thatprovided examplesof quality

２. Research on ICT-Based Medical Education Contents Based on Clinical
Practice and on Computer-Based Testing for the National Medical
Examination（１）Purpose of research
The purpose of this project is to create standardized, high-quality
medical education content using ICT that matches each phase of
medical education, including pre- and post-graduate education andlifelong education, in Japan, and to establish a system that can be widelyused by everyone from medical students to clinical doctors, in order toenhance medical education in Japan and improve the quality of medicalcare.
In addition, since the introduction of a computer system to thenational medical examination was announced at the 2020 "National
Medical Examination Improvement Study Group", we are creating
multimedia format examination questions using images, sounds, videos,etc. , the purpose of which is to implement a trial test via the Internet
and to construct a new test system using ICT.
（２）Research results
A．Research on the creation of medical education content
As the first step in creating all-made-in-Japan educational materials,
15 members from 13 medical education facilities nationwide developed
scenarios for 20 symptoms of the model core curriculum, including62

disorders of consciousness, abdominal pain, jaundice, etc., in
accordance with a manual for standard creation procedures, and aresequentially creating medical education content on Moodle, one of thelearning management systems. In the last fiscal year, scenarios for 12
symptoms were created, and in the final year, scenarios for 50
symptoms will be created, and a system that can be widely used by
medical students will be constructed.
B ． Research on CBT （ Computer-Based-Testing ） for national
examination for medical practitioners
The National Medical Practitioner Trial Examination was conducted at
15 universities across the country in one day via the Internet. The trial
exam consisted of 200 questions , which are based on the current
national examination standards, as in the previous year. In the trial test,
videos and other information were played back smoothly without system
trouble. It was conducted with the cooperation of a total of 450 medical
students (mainly 5th year students). 99 (48%) of the questions
incorporated some form of multimedia: video, image, or audio questions.
We were able to create questions that were closer to actual clinicalpractice by incorporating multimedia files that used video and audio into
the questions. A questionnaire was conducted after the trial test, andgenerally positive response were obtained regarding the implementationof the trial test.

63

【８】Others
１. International Activities
The International Society for Quality in Health Care (ISQua) runs anInternational Accreditation Program (IAP), which is a global accreditation
service to health care external evaluation organizations.
JQ had already been certified in " External Evaluation Organisations"and " Health and Social Care Standards", and both certifications renewedin 2022.
We will continue to work on quality improvement activities atinternational standards, collect the latest information from around theworld through our relationship with ISQua, and utilize it for our businessgoing forward.
２．Public Relations（１）Publication of newsletters, etc.
The Newsletter, which is JQ’s periodical for the stakeholders
introducing‘our activities, was published three times in 2022 and sent toaccredited hospitals nationwide, various academic societies, supporting
members, medical associations, etc. It was also posted on JQ website
to actively disseminate information so that more people can access it.
（２）Other public relations correspondenceIn fiscal 2022, in addition to holding four press conferences, we cosponsored and supported academic conferences and symposiums heldby medical-related organizations as follows.
Requester1

April

Conferences and Symposiums
SupportLead exhibition
Japan Co., Ltd.

Comprehensive

medicalandnursing care exhibition (Medical
Japan Tokyo/Osaka)
October 12-14, 2022 (Tokyo)
January 18-20, 2023 (Osaka)

2

May

Japan

SocietyofSupport2022 "Medical Safety Manager

MedicalTraining Seminar" (held locally)

Technologists

October 14-15, 2022 December
16(on-demand)

October1-

November 30, 2022 December

64

1-27
3

June

The

Japanese

Society for Medical
and

Co-

FY2022 Medical Device Safety

sponsorBasic

Seminar(44th

ME

BiologicalTechnical Seminar) e-learning

Engineering and theAugust 3-November 28, 2022

Medical

DeviceCenter
4

July

Japan

MedicalSupport

The

11th"National

MedicalPractical

Research

Management

Manager

Practice Association

Conference" Web Conference
November 1-30, 2021 (web)

5

July

Japan

SocietyofSupport17th Annual Meeting of theMedical Quality andSociety for Quality and Safety of

SafetyMedical Care
November 26-27, 2022

6

July

Health Policy Bureau,

Support

Ministry of Health,

Medical Safety Promotion Week
November 21-27, 2022

Labor and Welfare
7

Septembe

Medicalr

Promotion Council

TQM

Support

The

23rd

Forum

"Medical

Improvement Activities"
November 18-19, 2022 (Tokyo)

8

October

SupportGeneralThe 32nd Symposium of theIncorporated

GeneralFoundation Medical-

Foundation

RelatedService Promotion Association

Service

Promotion

Incorporated
Medical-related

February 3, 2023 (Tokyo)

Association
9

DecemberPublicInterest

Support

Incorporated

The 33rd Annual Meeting of theJapan

SocietyforClinical

Association

Japan

Engineering

Society

ClinicalJuly 21-23, 2023 (Hiroshima)

ofEngineers
10

JanuaryJapan
Association

Hospital

SupportandInternational Modern HospitalShow 2023

Japan Management

July 12-14, 2023 (Tokyo)

Association11

February

Japanese Society ofSupport65

International Conference forAnesthesiologists

Safe Anesthesia
February 9-11, 2024 (Tokyo)

12

March

All

Japan

Hospital

Support

Association

The 64th All Japan HospitalSociety in Hiroshima
October 14-15, 2023

13

March

Japan

MedicalSupport

The 72nd Annual Meeting of theManagement

Japan

SocietyofConsultants

Management Consultants Kyoto

Association

Convention
November 16-17, 2023

66

Medical３．Number of JQ staff(As of March 31, 2023, excluding maternity leave of absence)full-time

part-time

Seconded

Temporary

①

Resea
rcher

Foundation
GeneralCoordinator
GeneralAffairs
Quality
Improvement

Hospital
Accreditation

Education andTraining

time

②

①

+

Contract

part-

g

TOTAL

Regular

Visitin

TOTAL

TOTAL

Division

②

job

1

0

1

0

2

0

0

0

2

2

0

0

0

2

0

0

0

2

11

0

0

2

13

0

2

2

15

15

1

0

2

18

1

1

2

20

20

1

0

7

28

1

1

2

30

8

0

0

1

9

0

0

0

9

34

3

10

11

58

18

3

21

79

8

0

0

2

10

5

0

5

15

4

1

1

4

10

1

2

3

13

103

6

12

29 15026

935 185Japan
Obstetrics
Compensation
System for
CerebralPalsy
EBM and
Guidelines

Adverse Event
Prevention
total

67

４．Supporting member(As of March 31, 2023)
Member B
Types ofsupporting
members

Member A(Medical institutions,(Various organizations

various health/companies )

insurance

Member C(Researchers at
educational

associations, etc.)

Annual fee
Status500,000 yen

Member

300,000 yen

Withdrawal

ship

Membership

TOTAL

institutions, etc.)

20,000 yen

Withdrawal

Membership

Withdrawal

Membership

Withdrawal

Enrollment/withdrawal status

1995

28

6

24

2

8

2

60

10

1996

11

2

39

1

8

0

58

3

1997

3

0

1

0

0

0

4

0

1998

2

0

1

0

0

0

3

0

1999

0

2

5

2

0

0

5

4

2000

1

1

11

6

0

2

12

9

2001

2

1

3

3

1

0

6

4

2002

2

3

12

6

1

3

15

12

2003

2

0

6

2

0

0

8

2

2004

1

0

3

3

0

0

4

3

2005

1

0

1

2

1

0

3

2

2006

0

3

1

2

0

0

1

5

2007

0

5

0

9

0

4

0

18

2008

1

3

0

6

0

3

1

12

2009

0

2

0

9

0

0

0

11

2010

0

1

0

3

0

1

0

5

2011

0

0

0

6

0

2

0

8

2012

0

0

0

2

0

0

0

2

2013

0

3

0

4

0

1

0

8

2014

0

3

0

4

0

0

0

7

2015

0

0

0

1

0

0

0

1

2016

0

0

0

2

0

0

0

2

2017

0

0

0

2

0

0

0

2

2018

0

1

0

0

0

1

0

2

2019

1

0

0

1

0

0

1

1

2020

0

1

0

0

0

0

0

1

2021

1

0

1

0

0

0

2

0

2022

4

2

0

2

0

0

4

4

60

39

108

80

19

19

187

138

total

68

Number ofcurrent

21

28

0

49

members

June 2, 2023
Japan Council for Quality Health Care69