Beginning in 1992, the objective of Aso Iizuka Hospital’s TQM activities has been to learn the PDCA cycle through practice using QC methods. QC has enjoyed many successes in industry and other fields of business, and was adopted because it was felt to be one of the most effective methodologies to realize our Corporate Principle:“ We Deliver The Best.” Following the QC story of: theme selection, understanding of present state, goal setting, root cause analysis, planning and application of measures, confirmation of improvement, halting of negative tendency and installation of new standard, we carry out improvement of operations and efficiency based on evidence. We study and apply the “seven tools of QC,”methodologies that are useful for data collection and analysis, and reasoning. Our activities have brought many positiv e results which have been standardized to improve day-to-day operations and to realize better services. The activities outlined here have made Aso Iizuka Hospital a focus of attention for hospitals all over Japan and overseas, and our TQM Annual Conference attracts 600 attendees in the field of healthcare from all over the country. We also receive requests from many hospitals to accept study tours and send out staff to make presentations regarding these activities. By documenting and presenting the substance of our quality control, we are able to ensure that our staff, including those in leadership positions, consolidate their competence in improvement.
Because we provide acute and advanced medicine at Aso Iizuka Hospital, we also place emphasis on ensuring medical safety. Based on our own independent standards, we have systematized the flow of reporting and analysis of incidents and accidents followed by the introduction of improvements, in putting medical safety into practice. Efforts made by the hospital’s“Safety Promotion Office,” which is led by doctors, nurses and other full-time staff familiar with medical practice, as well as being aided by ISO and TQM activities that have cultivated an environment of improvement, have enabled us to perceive problem areas as t hose a ffecting the entire hospi tal an d implement measures accordingly. In addition, case examination meetings are held for nursing staff, which promote not only individual skill levels, but through feedback of participants, also enhance the entire workplace. With the watchword “no one from amongst patients, their families and medical staff should go through hardship,” we work to eliminate medical accidents and ensure medical safety through everyday efforts and joint research with the University of Tokyo and Waseda University.
ISO internal audit
Internal audits are conducted to confirm that QMS is implemented and maintained appropriately, and to facilitate its continuous improvement. A feature of Aso Iizuka Hospital’s internal audit is that paired departments conduct mutual audits of each other. This follows two-year cycles under which an audit team from one department will audit the other in one year, and then vice versa in the following year. Strengths and areas for improvement revealed by internal audits are reported to the Hospital Director in a management review. In cases where areas for improvement are cited, the audit team concerned will carry out continuous follow-up until improvement is verified. Department leaders naturally gain ability to lead by taking the initiative in internal audits, and staff acquire problem-solving abilities through TQM activities, giving the hospital more power to drive the PDCA cycle.
Using the TOYOTA Production System and Virginia Mason Production System as guides, since 2010 we have been making efforts to implement lean management as an improvement methodology with emphasis on speed and “Patient First ”which is one course of action involved in realizing the mission of the hospital. Under lean management cultivated through Kaizen combined with new perspectives, we are pursuing speedy improvement activities with an emphasis on the customer’s point of view. As part of our efforts,“ Kaizen Workshops”are held three times a year, during which participants spend two days away from their regular duties and give their undivided attention to improvement activities, as they plan, implement and measure the effectiveness of countermeasures for problem areas of participating departments. These are not simply two-day events but a system built for effective improvement activities, with the current state of problem areas being investigated prior to workshops, and follow-up being carried out for a subsequent period of three months.