School of Public Health, Kyoto University Graduate School of Medicine

Transcription

1 First author: Kenshi Hayashida, PhD, RN Co-authors: Yuichi Imanaka, MD, PhD, MPH Haruhisa Fukuda, MPH addresses: Kenshi Hayashida : kenshi@pbh.med.kyoto-u.ac.jp Yuichi Imanaka : imanaka@pbh.med.kyoto-u.ac.jp Haruhisa Fukuda : halu@pbh.med.kyoto-u.ac.jp The name and address of the institution: Department of Healthcare Economics and Quality Management School of Public Health, Kyoto University Graduate School of Medicine Yoshida Konoe-cho, Sakyo-ku, Kyoto , JAPAN Corresponding author: Yuichi Imanaka Phone: / Fax.: imanaka@pbh.med.kyoto-u.ac.jp 1

2 In Japan, as in other countries, several quality and safety assurance activities have been implemented since 1990 s. There have been few studies aimed at comprehensively analyzing these activities at the hospital level. The aim of this study was to develop a framework for analyzing hospital-wide activity for patient safety and infection control, and to measure the activity volume systematically by the framework. Using the conceptual framework of incremental activity corresponding to incremental cost, we defined the scope of patient safety and infection control activities and drafted a questionnaire to analyze them. After several rounds of revisions, we implemented the questionnaire and conducted several face-to-face interviews with managers and other staff in charge of patient safety and infection control in seven acute care teaching hospitals in Japan. At most hospitals, nurses and clerical employees were assigned and acted as the main actors in patient safety practices. The annual activity volume ranged from 14,557 to 72,996 person-hours across participant hospitals. Pharmacists performed more incremental activities than their proportional share in the head-count. In infection control activities, annual activity volume ranged from 3,015 to 12,196 person-hours, and medical doctors and nurses tended to perform somewhat more of the duties relative to 2

3 their share in the head-count. We developed a framework to analyze hospital-wide incremental activities for patient safety and infection control in Japanese teaching hospitals. Using this framework to survey seven hospitals in Japan, we found that the volume of these activities was large. Government or hospital decision-making can benefit from this type of systematic and empirical findings. 3

4 Recently in Japan, as in other countries, several quality and safety assurance activities have been executed through either voluntary actions on the part of individual hospitals or through external policy or legislative pressures 1. This remarkable movement has resulted from an increasing awareness of and demand for patient safety and quality assurance. It has been proposed that the main drivers of this movement have been 1) the beginning of the third party accreditation of hospitals in 1997 through the Japan Council for Quality Health Care (JCQHC) 2 ; and 2) the shocking medical accident that occurred in 1999, in which the attending surgeon mistook one patient for another. Despite these important developments, there have been few studies aimed at comprehensively analyzing these activities at the hospital level. A primary reason for this has been the difficulty in defining which activities are part of routine medical care and which ones are specifically part of patient safety and infection control practices. It is critical that a comprehensive methodology is developed to frame this issue because 1) it is important for both hospitals and policymakers to be able to consider a standard metric in evaluating these activities both across hospitals and over time; and 2) a standard measurement framework is central to any analysis of the potential costs and benefits of patient safety practices. These considerations are especially true in Japan, where it remains the case that hospitals typically underutilize critical patient safety practices. 4

5 The aim of this study was to develop a framework for analyzing hospital-wide activity for patient safety and infection control, and to measure the activity volume systematically by the framework. 1. Scope of activity for patient safety and infection control To define the scope of patient safety and infection control practices, we used the concept of incremental activity corresponding to incremental cost. Namely, the incremental activity was defined as the additional patient safety and infection control of a hospital that was been provided in the present year compared to the typical activity levels related to quality and safety in 1999 (the base case). In other words, we treated activities that have been introduced or strengthened since 1999 as patient safety and quality assurance. This approach was valid because, in Japan, the major developments in patient safety and quality assurance have taken place since Although medical advances have also occurred during that time, basic patient care practices have not significantly altered relative to patient safety and infection control. Interest in patient safety practices increased markedly in 1999 following highly publicized medical accidents. This resulted in an analysis of the topic published by the Ministry of Health, Labour and Welfare. 3 This was first major action for improving patient safety undertaken by the Japanese government. It also first established the accreditation system of infection control doctors (ICD) in , 5 5

6 2. Hospitals surveyed shows the characteristics of the subject hospitals. Each hospital had more than 300 beds and made strong efforts for patient safety and quality assurance. They were located throughout the country, and the ownerships of them were various, including public sector, healthcare corporations, and company. This study was approved by the Institutional Review Board of the Faculty of Medicine at the Graduate School of Medicine of Kyoto University. This survey was conducted from Aug 2005 to Mar Development of framework and questionnaire items To develop a framework to measure hospital-wide activity volume for patient safety and infection control, we reviewed the findings from past international studies 6-11 and reviewed the items of the JCQHC hospital accreditation standards. We also collected activity items put on a website and public relations magazines of a variety of hospitals. We developed a framework by using these investigations, through interviews with hospital managers and staff in charge of patient safety and infection control, and through panel discussions with experts. shows the framework to measure hospital-wide activity volume for patient safety and infection control. Domains common to both patient safety and infection control included staff assignment, meeting and conference, internal review and walk rounds, internal education and training, external 6

7 education and training, standard manual development, and other. In addition, they included incident reporting, external audits, and maintenance of medical equipment, and management of medications for patient safety, and infection surveillance for infection control. Based on the framework, we developed questionnaire items. In the questionnaire item of staff assignment, we calculated the amount of time spent working on the specific activity by the type of professional. Besides, we gathered activity contents, the head-count classified by professional (medical doctor, nurse, pharmacist, other medical staff, clerical employee, and others), the activity time per year, and the frequency of each activity to calculate the annual activity volume of person-time in For example, in the case of a supreme decision-making board committee of patient safety, we asked how many people belonged to the committee, which specialties the members belonged to, how many hours were spent for the functioning of each committee, and how many times the committee met during Each gathered activity was activity which has been introduced or strengthened since 1999 specifically for the purpose of patient safety and quality assurance. 4. Subjects and data collection methods We conducted self-administered questionnaire and several face-to-face interviews for the managers of divisions in charge of patient safety and infection control in seven acute care teaching hospitals. Typically, because responsibilities for patient 7

8 safety and for infection control were separate, we undertook distinct questionnaires for the staff and managers of these divisions. Moreover, if necessary, we also asked a variety of staff duties at key locations such as nursing sections, the pharmaceutical sections, and office work sections to participate in this survey. In order to partially control for differences in definitions and scopes of activity between hospitals, we sent the list of all the collected activity contents to each hospital and requested each to report whether the hospital offered information of all the executing activities. shows the head-count assigned to patient safety and infection control divisions or their equivalents by the type of professional. Divisions in charge of patient safety typically were staffed by nurses and clerical employees. There were 6 (85.7%) hospitals with at least one nurse or clerical FTE in these divisions. In almost all hospitals, these types of specialties were assigned. The members of the division in charge of infection control varied significantly between hospitals. Generally, either medical doctors or nurses were mainly assigned in these divisions. Unlike patient safety, other medical staff were assigned at relatively high proportions. shows volume of activity breakdown of patient safety and infection control by each hospital. In these tables, Model_1 and Model_2 show the average of all the seven hospitals calculated after conversion of each hospital s value into that per 100 beds and that per 100 staff, respectively. Activity volumes for patient safety ranged from 8

9 14,557 to 72,996 person-hours across participant hospitals. The mean volume of activity per 100 beds and per 100 staff were 6,240 person-hours and 3,323 person-hours, respectively. Whereas management of medications was the most common activity in 5 hospitals, either internal review and walk rounds or internal education and training was most common in the rest of each hospital. Although the incremental activity of management of medications was zero in hospital F, there were in fact patient safety and infection control activities in place. These activities had been in place before 1999, however, and thus did not contribute to the incremental level. In the activity of infection control, the activity volume ranged from 3,015 to 12,196 person-hours across participant hospitals. This activity volume was relatively smaller than that of patient safety. The mean volume of activity per 100 beds and that per 100 staff were 1,141 person-hours and 613 person-hours, respectively. The most common activity varied by hospital, with 3 hospitals having education, 1 having internal review and walk rounds. shows the share of each professional in the head-count and that in activity volume for patient safety or infection control. In the activity of patient safety, pharmacists performed more activities than their proportional share in the head-count. On the other hand, in the activity of infection control, medical doctors and nurses tended to perform somewhat more of the duties relative to their share in the head-count. In examining the economies of scale, a trend could be found only for nurses although the sample size was small ( ) This could imply that the more nurses that the 9

10 hospital had, the smaller the volume activity per nurse was. In this figure, a part of huge amount activity volume per pharmacist (about 700 hours in four hospitals) was excluded. In this study, we developed a framework for analyzing hospital-wide activity for patient safety and infection control, and measured the activity volume systematically by the framework in seven Japanese hospitals. In the organization of division in charge of patient safety, nurses and clerical employees typically formed the bulk of the staff. On the other hand, in infection control division, medical doctors and nurses tended to be more often assigned. The activity volume of patient safety and that of infection control ranged from 14,557 to 72,996 (per 100 beds: 6,240; per 100 staff: 3,323) and from 3,015 to 12,196 (per 100 beds: 1,141; per 100 staff: 613) person-hours across participant hospitals, respectively. These were relatively large volumes considering that the total annual incremental activity per 100 staff was about 4,000 person-hours, i.e., 2 person-years. These results suggest that many investments were needed for quality and safety assurance. Although the most common activity of patient safety was management of medications, that of infection control varied across the hospitals. In examining the relationship between the share of each professional in the head-count and that in activity volume for patient safety, the pharmacists performed a relatively large amount of activities for patient safety in spite of few staff assignment. For infection control, 10

11 medical doctors and nurses tended to perform slightly more, but their share of activity volume was similar to the proportion of staff assignment. Previous studies 12, 13 have suggested that the pharmacists are key players in patient safety, which supports the widespread employment in patient safety activities that was seen here. In examining the relationship between head-count by the type of professional and activity for patient safety and infection control per staff, the results could imply availability of economies of scale. There are several important features of our study. First, we introduced the concept of incremental activity, corresponding to incremental cost, into the extraction of the activity of patient safety and infection control. By this definition, the scope of their activities was specified, and as a result, we could extract more useful information. This was made possible by utilizing the unique Japanese context in which 1999 was a watershed year in the development of patient safety and infection control practices. Second, we obtained much useful information for many hospitals that have yet to perform patient safety and infection control practices. As mentioned above, there are few hospitals performing vigorous activities and little available information about them in Japan. As such, there was a possibility for hospitals to learn from other hospitals situation. Finally, we also obtained potentially useful information for improving the reimbursement system and reallocating resources for the sustainability of healthcare. Recently, the volume of patient safety and infection control activities remarkably increased, but the costs of these activities are not yet covered in the current payment 11

12 system. Thus the systematic and empirical findings presented here would be useful for the establishment of safe and durable system of healthcare delivery. Some limitations must be considered when interpreting the results of our study. First, it may not necessarily be the case that the hospitals selected in this study were representative hospitals of performing vigorous patient safety and infection control practices in Japan. In selecting participant hospitals, we utilized several pieces of information, such as reputation, public relationship descriptions on the homepage, and magazine and newspaper articles. This ensured that participant hospitals would be among the most likely to have implemented the most rigorous practices. Second, we could not get information on the activities performed by small groups, such as activity at each ward level. The aim of this study was to grasp the hospital-wide activities, however, and, given time and financial limitations, the approach taken here was likely the most effective at achieving this objective. Future studies should further develop a framework to estimate the contribution of information technology system such as ordering systems and electronic medical charts. Since a part of the activity for patient safety can be supplemented with information technology system 14-16, it is necessary to grasp the contribution of this. We also need to develop a framework to estimate activities surrounding the informed consent, since this process is an important factor in informed decision 17 and reducing medical errors. Recently, Japanese hospitals have started to appropriate greater numbers of medical professionals and have allotted longer times for the informed 12

13 consent process. We developed a framework to analyze hospital-wide incremental activities for patient safety and infection control and found that the volume was large. In the future, government or hospital decision-making about resource allocation to patient safety and infection control activities can benefit from this type of systematic and empirical findings. 13

14 None declared. YI conceived of the research. KH and HF collected the data and performed data analysis. KH wrote the first draft of the manuscript. All authors read and approved the final version of the manuscript. The authors are grateful to the staff at the seven hospitals who participated in this study. This study was supported in part by the Health Sciences Research Grants for the Research on Policy Planning and Evaluation from the Ministry of Health, Labor and Welfare of Japan (H16-Policy-014) and the Grant-in-aid for Scientific Research A from the Ministry of Education, Culture, Sports, Science and Technology of Japan ( ). 14

15 1. The Ministry of Health, Labour and Welfare. Available at: anzen/index.html. (accessed 10 Nov 2006) (in Japanese) 2. Hirose M, Imanaka Y, Ishizaki T, Evans E. How can we improve the quality of health care in Japan? Learning from JCQHC hospital accreditation. Health Policy. 2003;66(1): The Ministry of Health, Labour and Welfare. Toward prevention of incorrect patient recognition: Study report on prevention of accidents due to incorrect patient recognition. Tokyo: Mikusu; (in Japanese) 4. Tsuji A. [The introduction of ICD, ICN in Japan, and future expectations]. Nippon Rinsho. 2002;60(11): (in Japanese) 5. The institution conference of ICD. Available at: (accessed 10 Nov 2006) (in Japanese) 6. Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol. 1985;121(2): Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002;288(4): Pittet D, Allegranzi B, Sax H, Bertinato L, Concia E, Cookson B, et al. Considerations for a WHO European strategy on health-care-associated 15

16 infection, surveillance, and control. Lancet Infect Dis. 2005;5(4): Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ). 2001(43):i-x, Institute of Medicine. To Err is Human: Building a safer Health Care System. Washington DC: National Academy Press; Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in healthcare personnel, Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1998;19(6): Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. Pharmacotherapy. 2002;22(2): Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy. 2006;26(6): Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15): Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348(25):

17 16. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10): Epub 2006 Apr Agency for Healthcare Research and Quality. Patient Fact Sheet: 20 Tips to Help Prevent Medical Errors. Available at: (accessed 10 Nov 2006) 17

18 Figure 1-1 Share of each professional in head-count and that in incremental activity volume for patient safety Figure 1-2 Share of each professional in head-count and that in incremental activity volume for infection control Figure 2 Relationship between professional head-count and incremental activity for patient safety and infection control per staff Table 1 - Characteristic of subject hospitals Table 2 Framework to measure incremental activity volume for patient safety and infection control Table 3 Professional head-count assigned to patient safety division and infection control division or its equivalent Table Incremental activity volume of each activity item by hospital (Patient safety) Table Incremental activity volume of each activity item by hospital (Infection control) 18

19 Table 1. Characteristic of subject hospitals (approximate figure) A B C D E F H Number of bed 390 1, Number of inpatient per year 114, , , , , , ,000 Number of outpatient per year 317, , , , , , ,000 Number of surgery per year 2,700 11,300 4,500 3,300 3,400 5,400 3,300 Number of medical doctor Number of nurse Number of pharmacist Number of other co-medical staff Number of clerical employee Number of other staff

20 Table 2. Framework to measure incremental activity volume for patient safety and infection control Domain Scope and example 1. Staff assignment Staff assigned to the division of patient safety or infection control to be in charge of their activities 2. Meeting and conference 3. Internal review and walk rounds 4. Internal education and training 5. External education and training 6. Standard manual development 7. Incident reporting 8. External audit Meeting and conference which is held for patient safety and infection control (e.g. supreme decision-making board committee, medical accident investigation committee, regular staff meeting, infection control committee, etc.) Internal check for patient safety or infection control (e.g. review for adherence to manual, clinical chart review, and clinical conference, etc.) Education and training program set up and run inside hospitals (e.g. orientation for new comer, and seminar of patient safety or infection control, etc.) Education and training program set up and run outside hospitals (e.g. seminar conducted by government and professional organization, etc.) Standardization of process and manual preparation and revision aimed for patient safety or infection control (e.g. management code and handbook for patient safety or in-hospital infection control, etc.) Data collection and analysis, and measure of incident reports, adverse events and near misses to assure patient safety Third-party evaluation to continuously improve the safety and quality of care (e.g. the Japan Council for Quality Health Care, and International Organization for Standardization, etc.) 9 Maintenance of medical equipments Maintenance to prevent medical accidents (e.g. check and repair of medical equipment, etc.) 10 Management of medications 11 Infection surveillance 12 Other activity Management to prevent medical accidents (e.g. medication history management, drug information service, and dispensing instruction, etc.) Data collection and analysis, and measure of in-hospital infection (e.g. review of medical chart and bacteriologic examination of surgical site infection and catheter-related infection, etc.) Other activity related to patient safety and infection control and not categorized as above activity (e.g. campaign, issue of public relationships magazine, or newspaper related patient safety or infection control, etc ) 20

21 Table 3. Professional head-count assigned to patient safety division and infection control division or its equivalent Patient safety division Medical doctor Nurse Pharmacist Other co-medical staff Clerical employee Other staff Hospital Code N FTE N FTE N FTE N FTE N FTE N FTE A 0 (0) 0 (0) 0 (0) 0 (0) 2 (1.85) 0 (0) B 3 (0.5) 1 (1.0) 1 (0.4) 0 (0) 1 (1.0) 0 (0) C 0 (0) 1 (0.5) 0 (0) 0 (0) 2 ( ) 0 (0) D 2 (0.2) 3 (1.2) 1 (0.1) 2 (0.2) 2 (2.0) 0 (0) E 1 (0.1) 1 (1.0) 0 (0.0) 1 (0.1) 0 (0) 0 (0) F 1 (0.1) 1 (1.0) 1 (0.1) 0 (0) 1 (1.0) 0 (0) H 0 (0) 1 (1.0) 0 (0) 0 (0) 1 ( ) 0 (0) Infection control division A 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.05) 1 (0.08) B 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) C 0 (0) 1 (0.5) 0 (0) 0 (0) 1 (0.05) 0 (0) D 1 (0.6) 0 (0) 0 (0) 1 (0.8) 0 (0) 0 (0) E 2 (0.1) 1 (0.15) 0 (0) 1 (0.7) 0 (0) 0 (0) F 1 (0.8) 1 (1.0) 0 (0) 0 (0) 1 (1.0) 0 (0) H 1 (0.1) 2 (0.2) 1 (0.1) 1 (0.1) 0 (0) 0 (0) FTE : Full time equivalent (The number of person after convert to full time worker) 21

22 Table 4-1. Incremental activity volume of each activity item by hospital (Patient safety) (person-hour) Hospital Code A B C D E F H Model_1 Model_2 Number of bed Number of staff Meeting and conference 2,102 5,044 2,078 2, ,238 9, ( 5.5% ) ( 6.9% ) ( 13.5% ) ( 6.0% ) ( 2.8% ) ( 15.4% ) ( 24.4% ) ( 9.4% ) ( 9.3% ) Internal review and walk roun 108 1,875 1, ,657 2, ( 0.3% ) ( 2.6% ) ( 8.0% ) ( 1.6% ) ( 66.1% ) ( 18.7% ) ( 0.3% ) ( 14.6% ) ( 15.0% ) Internal education and trainin 2,375 4,354 1,239 5, ,090 1, ( 6.2% ) ( 6.0% ) ( 8.1% ) ( 14.3% ) ( 3.2% ) ( 28.1% ) ( 4.0% ) ( 7.5% ) ( 7.9% ) External education and trainin 2, ( 5.9% ) ( 1.1% ) ( 0.9% ) ( 0.3% ) ( 0.5% ) ( 0.5% ) ( 0.8% ) ( 1.9% ) ( 1.6% ) Standard manual development ,017 1, ( 0.2% ) ( 0.4% ) ( 3.6% ) ( 2.7% ) ( 5.0% ) ( 2.5% ) ( 0.2% ) ( 1.8% ) ( 2.0% ) Incident reporting 10,896 8,910 3, ,400 2,243 2, ( 28.5% ) ( 12.2% ) ( 24.0% ) ( 2.4% ) ( 5.6% ) ( 15.4% ) ( 6.4% ) ( 12.6% ) ( 12.0% ) External audit 1, Maintenance of medical equipments ( 4.4% ) ( 0.0% ) ( 0.0% ) ( 0.5% ) ( 0.0% ) ( 5.9% ) ( 0.3% ) ( 1.3% ) ( 1.2% ) 2,092 7,741 2,511 5,963 3, , ( 5.5% ) ( 10.6% ) ( 16.3% ) ( 16.0% ) ( 13.6% ) ( 0.0% ) ( 15.2% ) ( 11.6% ) ( 12.1% ) Management of medications 14,117 41,478 3,944 14, ,608 2,022 1,052 ( 37.0% ) ( 56.8% ) ( 25.7% ) ( 39.1% ) ( 1.6% ) ( 0.0% ) ( 40.9% ) ( 32.3% ) ( 31.8% ) Other activity 2,481 2, , ,955 3, ( 6.5% ) ( 3.4% ) ( 0.0% ) ( 17.1% ) ( 1.5% ) ( 13.4% ) ( 7.4% ) ( 6.9% ) ( 7.1% ) Total 38,201 72,996 15,372 37,259 25,186 14,557 40,648 6,262 3,307 The proportion of each activity item is shown in parentheses 'Model_1' shows the average of all the seven hospitals calculated after conversion of each hospital s value into that per 100 beds 'Model_2' shows the average of all the seven hospitals calculated after conversion of each hospital s value into that per 100 staff 22

23 Table 4-2. Incremental activity volume of each activity item by hospital (Infection control) (person-hour) Hospital Code A B C D E F H Model_1 Model_2 Number of bed Number of staff Meeting and conference 1,848 1, , , ( 29.5% ) ( 19.6% ) ( 17.9% ) ( 23.6% ) ( 18.0% ) ( 3.9% ) ( 24.9% ) ( 20.3% ) ( 19.9% ) Internal review and walk roun 252 1,817 1, ( 4.0% ) ( 32.8% ) ( 40.5% ) ( 6.6% ) ( 9.1% ) ( 4.1% ) ( 6.7% ) ( 10.1% ) ( 11.3% ) Internal education and trainin 1,973 1, ,494 1, ( 31.5% ) ( 32.8% ) ( 8.0% ) ( 15.5% ) ( 11.6% ) ( 28.6% ) ( 13.4% ) ( 20.6% ) ( 19.7% ) External education and trainin 1, ,697 1, ( 17.6% ) ( 1.2% ) ( 17.6% ) ( 4.4% ) ( 2.7% ) ( 13.9% ) ( 12.8% ) ( 11.0% ) ( 10.7% ) Standard manual development ( 7.0% ) ( 1.3% ) ( 3.6% ) ( 4.0% ) ( 2.3% ) ( 1.4% ) ( 2.3% ) ( 3.4% ) ( 3.3% ) Infection surveillance ,271 2, ( 3.2% ) ( 12.2% ) ( 7.7% ) ( 12.0% ) ( 24.6% ) ( 18.6% ) ( 27.6% ) ( 15.9% ) ( 15.7% ) Other activity , ,594 1, ( 7.2% ) ( 0.1% ) ( 4.7% ) ( 33.8% ) ( 31.8% ) ( 29.5% ) ( 12.3% ) ( 18.8% ) ( 19.4% ) Total 6,271 5,544 4,042 6,426 3,015 12,196 8,599 1, The proportion of each activity item is shown in parentheses 'Model_1' shows the average of all the seven hospitals calculated after conversion of each hospital s value into that per 100 beds 'Model_2' shows the average of all the seven hospitals calculated after conversion of each hospital s value into that per 100 staff 23

24 Figure 1 Figure 1-1. Share of each professional in head-count and that in incremental activity volume for patient safety Share of each professional in activity volume for patient safety (%) Share of each professional in head-count (%) Medical doctor Nurse Pharmacist Other co-medical staff Clerical employee Other staff

25 Figure 1-2. Share of each professional in head-count and that in incremental activity volume for infection control Share of each professional in activity volume for infection control (%) Share of each professional in head-count (%) Medical doctor Nurse Pharmacist Other co-medical staff Clerical employee Other staff

26 Figure 2. The relationship between professional head-count and incremental activity for patient safety and infection control per staff (hour) Incremental activity per staff Head-count by the type of profession Medical doctor Nurse Pharmacist Other co-medical staff Clerical employee Other staff A part of huge amount activity volume per pharmacist (about 700 hours in four hospitals) was excluded