Clinical Indicator

Clinical Indicators

Toranomon Hospital has established the following points as clinical indicators.

Main Building

No Item Significance of Index 2015
Calculation results
(numerator/
denominator)
Comments
1 Patient Satisfaction (Outpatient) Assessing the satisfaction level of the patient forthe duration of hospitalization and safe treatment as a result of treatment received is one out of the direct evaluation indices to measure the quality of medical treatment. 88.0%
(198/225)
2 Patient Satisfaction (Inpatient) 94.8%
(256/270)
3 Discharge Due to Death As the characteristics of the medical facility and profile of the patients admitted are different, the quality of medical care cannot be measured directly based on the ratio of the patients who died and patients who were discharged. 2.4%
(436/18,121)
4 Slips and Falls Among Inpatients This is one of the important indices to evaluate the quality of nursing care. 0.18%
(499/274,859)

From January 2014, the overturning and fall response team started their initiatives, during this period, they examined cases of overturning and falling, revised the response manual for overturning and falling, started rounds of the hospital wards, and implemented measures such as prohibiting patients from wearing slippers. In addition, the team worked to share information on overturning and fall incidents and damage rate over time by publishing data of each department and for the entire hospital.

Both incidence and damage rate improved and dropped below the average value. In 2016, overturning and fall prevention tools were updated, equipment was added, pictograms were introduced, and brochures handed over to patients were revised.

Injury Due to Slips and Falls Among Inpatients (Level 2 or Higher) 0.02%
(66/274,859)
Injury Due to Slips and Falls Among Inpatients (Level 4 or Higher) 0.004%
(10/274,859)
5 Incidence of Pressure Ulcers This is one of the important indices to evaluate the quality of nursing care. 0.04%
(121/270,787)
6 Referral Rate This is the percentage of patients who came to our hospital for the first time after being introduced by other medical institutions. This index shows the degree of cooperation with local medical institutions. 59.1%
(13,068/22,100)
7 Outgoing Referral Rate This is the percentage of patients who were introduced to other medical institutions. This index shows the degree of cooperation with local medical institutions. 86.0%
(19,016/22,100)
8 Utilization rate of indwelling urinary catheter This is the previous stage index for calculating the urinary tract infection, this index shows the number of patients for whom indwelling urinary catheter has been used. 11.9%
(32,571/274,859)
9 Symptomatic urinary tract infection incidence Urinary tract infection accounts for the maximum infection among healthcare-associated infections at approximately 40%. 80% of the infections are attributed to indwelling urethral catheter. Understanding the state in which the infection occurs is the first step to examine preventive measures. 0.1%
(33/32,571)
10 Response rate of ambulance and hotline This is the index to measure the function of emergency medical care, and represents the number of ambulance requests that was accepted. 89.6%
(3,962/4,422)
11 Administration rate of prophylactic antibiotics less than one hour before the start of surgery using specific surgical techniques If the site of the surgery has been performed gets infected after surgery, the hospitalization duration gets extended, and the medical expenses increase significantly. As one of the measures to prevent infection of the surgical site, antibiotics are administered before and after surgery. 99.2%
(645/650)
12 Stop rate of prophylactic antibiotics administration 24 hours (48 hours for cardiac surgery) after surgery using specific surgical techniques 73.3%
(473/645)
13 Selection rate of appropriate prophylactic antibiotics for specific surgical techniques 91.5%
(595/650)
14 Blood Sugar Control in Diabetic Patients HbA1c (NGSP) < 7.0% HbA1c is recommended to be maintained below 7.0% to prevent complications, and is one of the indices for determining the quality of diabetes care. In addition, changing the target values based on the state of the individual patients is important. 38.6%
(6,626/17,173)

HbA1c is the most useful index as a treatment goal for diabetes. However, goals suited for each individual have to be set in consideration of the patient's age, health condition, and ease of hypoglycemia occurrence. Moreover, the point that HbA1c may not adequately reflect the state of diabetes for patients with severe liver disease and anemia has to be noted.

In May 2016, a new treatment goal was set by a panel of the Japan Diabetes Society and Japan Geriatrics Society for elderly diabetic patients. The treatment goal was set in the range of 7% or more in patients with dementia and poor body condition depending on the degree.

15 Emergency medical care hospitalization rate less than 6 weeks after discharge
(Number of patients with unplanned hospitalization other than emergency medical hospitalization or emergency medical hospitalization)
This index is used to check if the treatment during initial hospitalization was adequate, or the patients were compelled to an early discharge with incomplete recovery. 4.1%
(722/17,821)
Rate of Emergency Medical Re-Admission Within Six Weeks after Discharge 2.4%
(428/17,821)
16 Early Administration of Aspirin to Acute Myocardial Infarction Patients (Within 48 Hours) Prescription of aspirin and β-blockers are recommended for the acute phase of acute myocardial infarction. 93.8%
(30/32)
Patients hospitalized with acute myocardial infarction were administered aspirin at an early stage during admission and discharge, special cases (such as gastrointestinal bleeding) were excluded.
17 Administration of Aspirin to Acute Myocardial Infarction Patients at Time of Discharge With the objective of improving long term prognosis after the onset of myocardial infarction, administration of antiplatelet drugs, β-blockers, ACE inhibitors or angiotensin II receptor antagonist (ARB), and statin are recommended. 96.9%
(31/32)
18 Administration of β-blockers to Acute Myocardial Infarction Patients at Time of Discharge 71.9%
(23/32)
Drugs such as β-blockers, statin, ARB, and ACE inhibitors that are supported with evidence can be increased, but cannot be set as a rule because the background of the patients is complicated.
19 Administration of Statins to Acute Myocardial Infarction Patients at Time of Discharge 71.9%
(23/32)
20 Administration of ACE Inhibitors or Angiotensin II Receptor Inhibitors to Acute Myocardial Infarction Patients at Time of Discharge 59.4%
(19/32)
21 Administration of ACE Inhibitors or Angiotensin II Receptor Inhibitors to Acute Myocardial Infarction Patients 66.7%
(22/33)
22 Initial PCI implementation rate within 90 minutes of the arrival of patients suffering from myocardial infarction to the hospital. To treat acute myocardial infarction, reperfusion therapy (treatment to resume blood flow in the blocked coronary artery) has to be performed as soon as possible after the onset. This is considered to be important for the improvement of prognosis. 66.7%
(18/27)
23 Administration of Antithrombotic Treatment to Stroke Patients By 2nd Day of Onset For the treatment of cerebral infarction, starting anti-thrombotic therapy (treatment to reduce the incidence of thrombosis) by the second day of hospitalization is recommended. 76.6%
(95/124)
For the indices of stroke, there are cases with complications, and drugs have to be selected appropriately to match the condition of the patients.
24 Prescription of Antiplatelet Drugs for Stroke Patients at Time of Discharge Antiplatelet drugs (drugs that control the functioning of platelets and prevent blood clotting) are effective for tertiary prevention of cerebral infarction. 77.6%
(83/107)
25 Percentage of stroke patients prescribed with statin during discharge This process index is used to observe the recurrence prevention contents after discharge from the hospital. 51.9%
(81/156)
26 Prescription of Anti-Clotting Drugs to Stroke Patients Diagnosed With Atrial Fibrillation at Time of Discharge Anti-clotting drugs (drugs that inhibit blood clotting) are said to be effective for cerebral infarction cases with atrial fibrillation complications. 90.9%
(10/11)
27 Early Implementation of Rehabilitation for Cerebral Infarction Patients During Hospitalization After the diagnosis of stroke, rehabilitation has to be started as soon as possible in accordance with the condition of the patient, this is linked to the early recovery and suppression of a drop in the functions. 61.2%
(74/121)
There may be cases where rehabilitation may not be recommended due to reasons such as general conditions.
28 Prescription of Steroid Inhaler for Asthma Patients During Hospitalization Inhaled steroids play a central role as the method for managing the chronic phase. 82.0%
(41/50)
29 Prescription of Oral or IV Steroids for Pediatric Asthma Patients During Hospitalization Oral and intravenous formulation of steroids to quickly alleviate the symptoms of an asthma attack has been recommended in the guidelines to reduce the severity. 90.5%
(19/21)
For infants with asthmatic bronchitis, the effect of steroids is low, and there is an improvement with inhalation of leukotriene antagonists and β, and administration of antibiotics. Therefore, systemic steroid therapy is not implemented.
30 Integrated indices [Surgery] Comprehensive evaluation of the stroke indices (No. 11., 12., and 13.). 88.1%
(1,713/1,945)
31 Integrated indices [Ischemic heart disease] Comprehensive evaluation of the stroke indices (No. 16., 17., 18., 19., 20., and 22.). 73.6%
(163/221)
32 Integrated indices [Stroke] Comprehensive evaluation of the stroke indices (No. 23., 24., 25., 26., and 27). 58.4%
(303/519)

Branch Building

No Item Significance of Index 2015
Calculation results
(numerator/
denominator)
Comments
1 Patient Satisfaction (Outpatient) Assessing the satisfaction level of the patient forthe duration of hospitalization and safe treatment as a result of treatment received is one out of the direct evaluation indices to measure the quality of medical treatment. 92.7%
(101/109)
2 Patient Satisfaction (Inpatient) 94%
(172/183)
3 Discharge Due to Death As the characteristics of the medical facility and profile of the patients admitted are different, the quality of medical care cannot be measured directly based on the ratio of the patients who died and patients who were discharged. 2.5%
(123/5,007)
4 Slips and Falls Among Inpatients This is one of the important indices to evaluate the quality of nursing care. 0.26%
(260/98,914)

From 2015, medical staff personnel periodically go on rounds of the hospital wards and perform a risk assessment of overturning and falling, safety measures, and status of arrangement around the beds along with the staff of each department and provide the results as a feedback.
Moreover, based on the analysis results, specific preventive measures are taken corresponding to the main causes for overturning and falling.
From 2016, the overturning and fall response team started their initiatives, and have engaged in cross-departmental activities to prevent overturning and falling.

* For the protection of personal information, - (hyphen) has been used in the case where the number of cases is below 10.

Injury Due to Slips and Falls Among Inpatients (Level 2 or Higher) 0.02%
(24/98,914)
Injury Due to Slips and Falls Among Inpatients (Level 4 or Higher) 0.006%
(-)
5 Incidence of Pressure Ulcers This is one of the important indices to evaluate the quality of nursing care. 0.03%
(33/97,026)
6 Referral Rate This is the percentage of patients who came to our hospital for the first time after being introduced by other medical institutions. This index shows the degree of cooperation with local medical institutions. 54.5%
(1,837/3,368)
7 Outgoing Referral Rate This is the percentage of patients who were introduced to other medical institutions. This index shows the degree of cooperation with local medical institutions. 73.4%
(2,471/3,368)
8 Utilization rate of indwelling urinary catheter This is the previous stage index for calculating the urinary tract infection, this index shows the number of patients for whom indwelling urinary catheter has been used. 8%
(7,936/98,914)
9 Symptomatic urinary tract infection incidence Urinary tract infection accounts for the maximum infection among healthcare-associated infections at approximately 40%. 80% of the infections are attributed to indwelling urethral catheter. Understanding the state in which the infection occurs is the first step to examine preventive measures. 0.3%
(24/7,936)
10 Response rate of ambulance and hotline This is the index to measure the function of emergency medical care, and represents the number of ambulance requests that was accepted. 69.2%
(245/354)
11 Administration rate of prophylactic antibiotics less than one hour before the start of surgery using specific surgical techniques If the site of the surgery has been performed gets infected after surgery, the hospitalization duration gets extended, and the medical expenses increase significantly. As one of the measures to prevent infection of the surgical site, antibiotics are administered before and after surgery. 100%
(83/83)
12 Stop rate of prophylactic antibiotics administration 24 hours (48 hours for cardiac surgery) after surgery using specific surgical techniques 53%
(44/83)
13 Selection rate of appropriate prophylactic antibiotics for specific surgical techniques 100%
(83/83)
14 Blood Sugar Control in Diabetic Patients HbA1c (NGSP) < 7.0% HbA1c is recommended to be maintained below 7.0% to prevent complications, and is one of the indices for determining the quality of diabetes care. In addition, changing the target values based on the state of the individual patients is important. 46.1%
(368/798)

HbA1c is the most useful index as a treatment goal for diabetes. However, goals suited for each individual have to be set in consideration of the patient's age, health condition, and ease of hypoglycemia occurrence. Moreover, the point that HbA1c may not adequately reflect the state of diabetes for patients with severe liver disease and anemia has to be noted.

In May 2016, a new treatment goal was set by a panel of the Japan Diabetes Society and Japan Geriatrics Society for elderly diabetic patients. The treatment goal was set in the range of 7% or more in patients with dementia and poor body condition depending on the degree.

15 Emergency medical care hospitalization rate less than 6 weeks after discharge
(Number of patients with unplanned hospitalization other than emergency medical hospitalization or emergency medical hospitalization)
This index is used to check if the treatment during initial hospitalization was adequate, or the patients were compelled to an early discharge with incomplete recovery. 5.3%
(260/4,929)
Rate of Emergency Medical Re-Admission Within Six Weeks after Discharge 4.1%
(201/4,929)
16 Early Administration of Aspirin to Acute Myocardial Infarction Patients (Within 48 Hours) Prescription of aspirin and β-blockers are recommended for the acute phase of acute myocardial infarction. No target patients
17 Administration of Aspirin to Acute Myocardial Infarction Patients at Time of Discharge With the objective of improving long term prognosis after the onset of myocardial infarction, administration of antiplatelet drugs, β-blockers, ACE inhibitors or angiotensin II receptor antagonist (ARB), and statin are recommended. No target patients
18 Administration of β-blockers to Acute Myocardial Infarction Patients at Time of Discharge No target patients
19 Administration of Statins to Acute Myocardial Infarction Patients at Time of Discharge No target patients
20 Administration of ACE Inhibitors or Angiotensin II Receptor Inhibitors to Acute Myocardial Infarction Patients at Time of Discharge No target patients
21 Administration of ACE Inhibitors or Angiotensin II Receptor Inhibitors to Acute Myocardial Infarction Patients No target patients
22 Initial PCI implementation rate within 90 minutes of the arrival of patients suffering from myocardial infarction to the hospital. To treat acute myocardial infarction, reperfusion therapy (treatment to resume blood flow in the blocked coronary artery) has to be performed as soon as possible after the onset. This is considered to be important for the improvement of prognosis. No target patients
23 Administration of Antithrombotic Treatment to Stroke Patients By 2nd Day of Onset For the treatment of cerebral infarction, starting anti-thrombotic therapy (treatment to reduce the incidence of thrombosis) by the second day of hospitalization is recommended. 66.7%
(-)
* For the protection of personal information, - (hyphen) has been used in the case where the number of cases is below 10.
24 Prescription of Antiplatelet Drugs for Stroke Patients at Time of Discharge Antiplatelet drugs (drugs that control the functioning of platelets and prevent blood clotting) are effective for tertiary prevention of cerebral infarction. 91.7%
(33/36)
25 Percentage of stroke patients prescribed with statin during discharge This process index is used to observe the recurrence prevention contents after discharge from the hospital. 45.9%
(28/61)
26 Prescription of Anti-Clotting Drugs to Stroke Patients Diagnosed With Atrial Fibrillation at Time of Discharge Anti-clotting drugs (drugs that inhibit blood clotting) are said to be effective for cerebral infarction cases with atrial fibrillation complications. No target patients
27 Early Implementation of Rehabilitation for Cerebral Infarction Patients During Hospitalization After the diagnosis of stroke, rehabilitation has to be started as soon as possible in accordance with the condition of the patient, this is linked to the early recovery and suppression of a drop in the functions. 33.3%
(-)

A direct comparison with the previous year is not possible because the definition of the index has changed. (The denominator reduced significantly because the target included only acute phase cerebral infarction)

* For the protection of personal information, - (hyphen) has been used in the case where the number of cases is below 10.

28 Prescription of Steroid Inhaler for Asthma Patients During Hospitalization Inhaled steroids play a central role as the method for managing the chronic phase. 75%
(12/16)
29 Prescription of Oral or IV Steroids for Pediatric Asthma Patients During Hospitalization Oral and intravenous formulation of steroids to quickly alleviate the symptoms of an asthma attack has been recommended in the guidelines to reduce the severity. No target patients
30 Integrated indices [Surgery] Comprehensive evaluation of the stroke indices (No. 11., 12., and 13.). 84.6%
(215/254)
31 Integrated indices [Ischemic heart disease] Comprehensive evaluation of the stroke indices (No. 16., 17., 18., 19., 20., and 22.). No target patients
32 Integrated indices [Stroke] Comprehensive evaluation of the stroke indices (No. 23., 24., 25., 26., and 27). 67.2%
(80/119)

Note) Japan Hospital Association, QI Project 2015
Click here to learn more about calculation methods.

Other

Average Daily Outpatient Clinic Visitors
(5 Years)

(People)

(People)

(Year)

  • Toranomon Hospital

  • Toranomon Hospital Kajigaya

2012 2013 2014 2015 2016
Toranomon Hospital 2630 2630 2688 2767 2719
Toranomon Hospital Kajigaya 539 546 543 540 517

Referral Rate (5 Years)

(%)

(Year)

  • Toranomon Hospital

  • Toranomon Hospital Kajigaya

2012 2013 2014 2015 2016
Toranomon Hospital 48.8 48.4 50.1 51.4 63.1
Toranomon Hospital Kajigaya 37.3 37.3 37.8 37.6 42.6

Ambulance Admission Rate (5 Years)

(Case)

(Case)

(Year)

  • Toranomon Hospital

  • Toranomon Hospital Kajigaya

2012 2013 2014 2015 2016
Toranomon Hospital 3425 3610 3578 3909 5001
Toranomon Hospital Kajigaya 248 237 242 258 257

Average Daily Number of Hospitalized Patients(5 Years)

(People)

(People)

(Year)

  • Toranomon Hospital

  • Toranomon Hospital Kajigaya

2012 2013 2014 2015 2016
Toranomon Hospital 740 751 739 749 752
Toranomon Hospital Kajigaya 259 265 264 268 263

First-Time Patient Admissions (5 Years)

(People)

(People)

(Year)

  • Toranomon Hospital

  • Toranomon Hospital Kajigaya

2012 2013 2014 2015 2016
Toranomon Hospital 16773 16945 17685 18203 17992
Toranomon Hospital Kajigaya 4780 4948 4896 5017 4705

Average Hospital Stay (5 Years)

(Days)

(Year)

  • Toranomon Hospital

  • Toranomon Hospital Kajigaya

2012 2013 2014 2015 2016
Toranomon Hospital 16.1 16.2 15.3 15.1 15.2
Toranomon Hospital Kajigaya 17.4 17.2 17.4 17.6 18.2

Hospital-based Cancer Registry by Major Site

Site 2012 2013 2014 2015
Colon or Rectum 462 520 587 610
Brain, nervous system 277 416 469 500
Breast 261 334 344 475
Stomach 420 422 425 398
Lung or trachea 299 361 350 346
Malignant Lymphoma 103 161 230 265
Esophagus 173 189 185 220
Prostate 102 112 153 179
Leukemia 68 141 117 163
Skin (Malignant melanoma) 101 115 115 126
Other Hematopoietic 79 104 97 114
Liver 74 105 97 99
Oropharyngeal 60 61 44 79
Kidney and other urinary organs 59 77 94 79
Pancreas 62 89 86 75
Bladder 37 51 57 67
Cervix uteri 38 38 38 44
Thyroid gland 19 43 47 44
Gallbladder and bile ducts 29 36 48 37
Corpus Uteri 29 32 27 21
Ovary - 12 18 18
Multiple myeloma 15 21 33 17
Larynx - - - -
Bone and articular cartilage - - - -
Uterus - 0 0 0
Others 60 70 61 83
Total 2845 3521 3741 4069

*For the protection of personal information, - (hyphen) has been used in the case where the number of cases is from 1 to 10.

Patient Satisfaction

Toranomon Hospital

Patient Satisfaction Rating (5 Years) (Inpatient)

  • Very Satisfied

  • Somewhat Satisfied

  • Average

  • Somewhat Dissatisfied

  • Not Satisfied

  • Very Satisfied

  • Somewhat Satisfied

  • Average

  • Somewhat Dissatisfied

  • Not Satisfied

Patient Satisfaction Rating (5 Years) (Outpatient)

  • Very Satisfied

  • Somewhat Satisfied

  • Average

  • Somewhat Dissatisfied

  • Not Satisfied

  • Very Satisfied

  • Somewhat Satisfied

  • Average

  • Somewhat Dissatisfied

  • Not Satisfied

Toranomon Hospital Kajigaya

Patient Satisfaction Rating (5 Years) (Inpatient)

  • Very Satisfied

  • Somewhat Satisfied

  • Average

  • Somewhat Dissatisfied

  • Not Satisfied

  • Very Satisfied

  • Somewhat Satisfied

  • Average

  • Somewhat Dissatisfied

  • Not Satisfied

Patient Satisfaction Rating (5 Years) (Outpatient)

  • Very Satisfied

  • Somewhat Satisfied

  • Average

  • Somewhat Dissatisfied

  • Not Satisfied

  • Very Satisfied

  • Somewhat Satisfied

  • Average

  • Somewhat Dissatisfied

  • Not Satisfied