International Journal for Quality in Health Care 1998; Volume 10, Number 4: pp. 361–363
Country report
Direction of quality improvement activities of health care organizations in Japan HIROTO ITO1, SAKAI IWASAKI1, YUKARI NAKANO1, YUICHI IMANAKA2, HIROFUMI KAWAKITA3 AND ATSUAKI GUNJI4 1
Department of Health Services Administration, Nippon Medical School, 2Department of Health Services Management and Policy, Division of Medical Science, Graduate School, Kyushu University, 3Japan Council for Quality Health Care, and 4Department of Health Administration, University of Tokyo, Japan
Since Japan introduced a universal health insurance system based on fee-for-service in 1961, the health status of the people of Japan has dramatically improved. Japan has achieved the world’s longest life expectancy at a fairly reasonable cost. People can access care regardless of their capacity to pay and can select any services without restrictions. Now there are some 9800 hospitals and 84 000 clinics throughout the country. Please note that in Japan, health care organizations with 20 or more beds are defined operationally as hospitals and those with less than 20 beds as clinics [1]. Japan still ranks among the lower half of advanced countries in the ratio of total health expenditure to the gross domestic product [2]. However, like other developed countries, Japan faces a fiscal crisis: due to a rapidly ageing population and fewer children, the 21st century is likely to be named ‘the century of the elderly’. As the economic pressure increases, issues such as the growing number of physicians entering practice, the longer length of hospital stay and heavy use of prescriptions by physicians become more controversial. Finally, in response to these problems, attention is being paid to the quality of health care, in order to provide optimal care at reasonable costs. The Japanese Society for Quality in Health Care (JSQua) has taken a leading role in the quality improvement activities of health care organizations since 1990. JSQua developed a third-party evaluation system based on the idea of forming a study group in the Private Hospital Association to study the activities of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the USA. In 1995, the Japanese Council for Quality Health Care (JCQHC) was founded with the aim of improving the quality of health
care organizations by conducting surveys using third-party evaluation methods.
Birth of quality improvement activities Despite a relatively short history compared with that of JCAHO in the USA [3], quality improvement activities in Japanese health care organizations are growing rapidly (Figure 1). In 1985, a committee was set up by the Japanese Medical Association and the Ministry of Health and Welfare to develop the self-check manual for health care organizations, and a survey of performance was conducted using the evaluation items that had been developed in 6433 participating hospitals (67.2% of the 9567 existing hospitals). The self-check manual consists of five categories (structure, role in the community, patient satisfaction, scientific basis and management) and contains 100 items. This was the first attempt to ensure the delivery of high quality care, and the basic framework of this manual was used in the third-party evaluation method in 1990s.
Growing interest in third-party evaluation – JSQua In 1987, the Private Hospital Association organized a study group with a few scholars. This group studied the overall
Address correspondence to Hiroto Ito, Department of Health Care Economics, National Institute of Health Services Management, Ministry of Health and Welfare, 1-23-1 Toyama, Shinjuku-ku, Tokyo 162-0052, Japan. Tel: + 81 3 3203 5327. Fax: +81 3 3202 6853. E-mail:
[email protected]
361
H. Ito et al.
Figure 1 History of Japan’s quality improvement activity
activities of the JCAHO in the USA and developed a model of third-party evaluation adapted for hospitals in Japan. Until the trial survey with this model took place, the idea of third-party evaluation was unknown in Japan. These initial efforts were continued by the more specialized society, namely JSQua. JSQua The Japanese Hospital Quality Assurance Society (JHQAS) was established in 1990, and was later renamed JSQua. There were about 60 member hospitals including leading hospitals in Japan and 50 individual members such as presidents, nurses and administrators in hospitals, as well as scholars. The goals of the Society were to create systems to improve quality in health care based on scientific data and to share all the information and experiences of these activities with the members. Although the government has already applied hardware checks of quality to health care organizations, such as minimum numbers for personnel and equipment, JSQua has its eye on software to try to inspect the nature of services by third parties. JSQua researchers developed the standards and scoring guidelines for evaluating health care. The first version of the standards was published in 1991, and it has been constantly updated since then. The standards include about 500 items in a number of categories such as patient satisfaction, nursing, medical records, and administration or management of health care organizations. A group of about 15 trained members conducted a 1-day
362
on-site survey using these standards and scoring guidelines. The group was divided into three subgroups: medical doctors, nurses, and administrators. After the three subgroups had rated the quality of the care, they discussed the results until they reached consensus. The recommendations were given to the hospital surveyed, usually about 3 months after the on-site survey. Member hospitals that experienced the survey may voluntarily improve their care based on the recommendation and will receive the follow-up survey from JSQua. The standards and scoring guidelines were examined at the time each hospital was surveyed and were revised annually (usually) by the surveyors who are experienced and trained through their survey work. The Society has conducted 38 surveys since 1991. Currently the Society is using version 5 for evaluation, and the surveyors are using the latest standards and scoring guidelines.
The new council for third-party evaluation – JCQHC Awareness of the necessity of the third-party evaluation led to the establishment of a nation-wide organization for third party evaluation in July 1995. This organization, the Japanese Council for Quality Health Care (JCQHC), is funded by the Government, the Japanese Medical Association, by hospital organizations, associations of health care professionals and by insurance organizations. However, JCQHC is independent
Quality improvement in Japan
of government and all other public or private groups. The JCQHC’s activities consist of developing tools – and making them widely available – for quality measurement, for training surveyors and for conducting on-site surveys in both general and psychiatric hospitals. Based on the results of feasibility studies including test surveys in 1996, the Council decided to begin a regular cycle of surveys in April 1997. JCQHC aims to conduct about 240 on-site surveys per year. It also plans to expand the limits of its survey activities to include specialized organizations such as geriatric hospitals, as well as general and psychiatric hospitals. Since JCQHC is an accreditation body run by fees from surveys, clear explanation to the hospitals is expected, and the accreditation process should help them to improve their quality of care. By the beginning of the next century, JCQHC’s goal is to conduct more than 1000 surveys a year. This means that onehalf of all the hospitals in Japan would be participating in this programme within a few years. The Council aims to create a system in which each hospital is surveyed regularly every 3 years. This is expected to be a driving force that will put quality of care checks into everyday practice.
Changing JSQua’s role With the establishment of the larger scale of survey organization, JSQua shifts its course, but will continue to take the pioneer role by addressing future directions. JSQua will concentrate on ‘think-tank’ tasks through data collection and analysis and through reviewing the current utilization strategies in the literature. For the present, a shift to more outcome-based standards is a challenge for JSQua because until now more attention has been paid to structure and process than to outcome. Some measurable indicators must be found that have been tested for validity and reliability.
Conclusion Looking back at our short history of quality improvement in health care, the initial impetus toward the movement was given by the Government and by the Japanese Medical Association. However, JCQHC and JSQua emerged independently of these efforts with a commitment to improving the quality of care in their roles as gatekeepers. A large number of surveys conducted by JCQHC will accelerate and expand general awareness of continuous quality improvement with the support of JSQua. Quality improvement activity in industrial fields is famous as KAIZEN[4] (a continuous search for opportunities to improve all processes) and has had a great impact on health care improvement in the USA [5,6]. Ironically, Japan is just starting towards a new stage of quality improvement activity with regard to health care. Hopefully, JCQHC and JSQua will promote the KAIZEN of health care organizations in Japan.
References 1. Ministry of Health and Welfare. Research on Medical Institutions. Tokyo: Ministry of Health and Welfare, 1995 (in Japanese). 2. Iglehart JK. Japan’s medical care system: Part two. N Engl J Med 1988; 319: 1166–1172. 3. Roberts JS, Coale JG, Redman RR. A history of the Joint Commission on Accreditation of Hospitals. J Am Med Assoc 1987; 258: 936–940. 4. Imai K. KAIZEN. New York: Random House, 1986. 5. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med 1989; 320: 53–56. 6. Joint Commission on Accreditation of Healthcare Organizations. Agenda for Change. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 1987. Accepted for publication 15 May 1998
363
