Introduction of the 7:1 system resulted in an increase in patient satisfaction and caused physicians and nurses to feel that their working hours had become shorter, whereas real working time was unaltered. In fact, the rate of physicians requiring care for Workload alone was significantly reduced under the 7:1 system, but the rates for other stressors were unaltered. The rates of nurses who required care were unaltered, and especially the rate of those requiring care for Workload remained higher than 90%. The 7:1 system is an incentive for hospitals with introduction of DPC, but its effect was not obvious in terms of hospital benefit.
After introducing a new system/program, it is important to examine the quality management and the validity of the system/program to improve its quality. The Deming cycle (Shewhart cycle), known as the plan–do–study–act (PDSA)/plan–do–check–act (PDCA) paradigm [15
], has been widely adopted worldwide, including in medical research/studies to test the effects and performance before and after the introduction of a new system/program [16
]. The DPC is newly introduced and, even though its study/check stage does not not yet seem to be sufficient, the new 7:1 system was introduced. It is necessary to study/check details from both inside and outside. Generally, worker satisfaction is related to inpatient satisfaction [8
]. For TQM, it is important to maintain the balance of worker quality of life and profits [16
]. Therefore, the present study was performed to evaluate inpatient satisfaction and job satisfaction/stress of medical workers simultaneously. Moreover, the effects of the introduction of the 7:1 system on medical workers’ estimation of the DPC function and on hospital profits were examined.
As DPC hospitals deal with patients with extremely serious conditions, it is not surprising that all SF-36 scores before hospitalization were lower than the national mean. Regardless of whether the patient was healthy or sick, scores in women are usually lower than those in men [5
]. This was also true in the present study. Low scores in Physical Functioning, Role-Physical, etc., led to significantly lower scores in the Physical Component Summary for women as compared with men, suggesting restriction of female mobility. There was no significant difference in the Mental Component Summary between men and women, but the significantly lower scores in Vitality and Role-Emotional for women suggests occult mental health risk among female patients. Nonetheless, Satisfaction scores reached “somewhat satisfied,” and therefore medical/nursing care under the DPC seemed well organized. Higher scores in all satisfaction items examined under the 7:1 system than the 10:1 system showed that introduction of the 7:1 system was somewhat beneficial for inpatients. Low scores for Dealing with Patients and Easiness of Consultation in factor analysis confirmed that the 7:1 system increased the number and duration of nurses’ rounds. A higher coefficient on multiple regression analysis for Nursing Care than for other types of care substantiated these findings. Physicians, who tended to be absent from the nurses’ station, should be easily accessible and deal with and explain care to patients both reliably and sincerely. Although disease care was important, care by physicians was more important in terms of “mental” care than in terms of direct contact, such as Coping with Patients’ Pain/Indisposition, which was usually considered to be Nursing Care rather than Medical Care.
In the 7:1 system, both physicians and nurses judged that their working hours had become significantly shorter than under the 10:1 system, although their real working hours were unaltered. The 7:1 system reduced the number of patients cared for by a single nurse at a time, whereas the time pressure due to shortened LOS continued, Therefore, the long working hours have not been improved for either physicians or nurses. Although the numbers of female physicians and male nurses are increasing, the majority of physicians and nurses are still male and female, respectively. Thus, nurses have heavier burdens at home than physicians, which may affect their estimation of Workload in a hospital/ward. However, more than 90% of nurses who required care in items of Workload in both systems showed no improvement in their workload in the 7:1 system. On the other hand, Personal Relations, Conformity, and Support by Coworkers/Supervisor for physicians and nurses were well administered regardless of the system, which may maintain a lower rate for those who required care for Mental and Physical Stress. This is a type of TQM performed by the workers themselves. However, the 7:1 system did not improve any of these qualities for either physicians or nurses. Moreover, the 7:1 system did not improve the Mental Stress of physicians or nurses, even though it slightly improved Physical Stress.
Understanding the DPC was categorized as “neither agree nor disagree” by the physicians and worse than “somewhat disagree” by the nurses, regardless of the nursing system. This was partly because some physicians and nurses only experienced the FFS at clinical training courses as a student, judging from their working years, and their knowledge about the differences between the FFS and DPC was limited. Even when they really did not know what type of system the DPC was, both physicians and nurses considered that introduction of the DPC could not always facilitate more efficient medical/nursing care, because all the scores were lower than “neither agree nor disagree.” Under both systems, physicians had to spend almost 1/3 of their working hours on paperwork/data input, so that the mean working h/week of the physicians in this hospital was similar to in other Japanese surveys [12
] and higher than in Organization for Economic Co-operation and Development (OECD) countries [20
]. One of the major purposes of the DPC [23
] was to shorten LOS. Both physicians and nurses did not judge LOS to be shorter or see an improvement in quality of medical/nursing care or in the working environment. Nonetheless, physicians tried to change the contents of medical care and the medicine/medical material.
Introduction of the 7:1 system is an incentive for hospitals introducing DPC to increase hospital profit but also causes an increase in the number of nurses needed, probably resulting in a deficit. Total profit of this hospital in 2008 increased compared with that in 2007. However, the percentage profit of 7 of 10 diseases became negative, and therefore this increase was dependent on the profit from the patients with the other 3 diseases, i.e., angina pectoris, heart failure, and hyperthyroidism. If the number of patients with these 7 diseases exceeded that with the other 3 diseases, the hospital would suffer a financial loss. Unfortunately, the profits under the DPC could be compared only with those under the FFS in the present study. As the DPC is new, there have not been many studies and surveys, so it is very difficult to confirm the appropriateness of the setting of the DPC coefficients and points to calculate medical expenses. It is unclear whether the current administration of a hospital/ward and/or clinical pass are suitable to such settings. These points should be taken into consideration for further evaluation of the DPC setting.
The 7:1 system showed advantages with regard to patient satisfaction, but not always for the QOL of the medical staff or hospital benefit, which are very important to maintain high quality of medical/nursing care. Physicians and nurses did not always understand what type of system the DPC was, and what was expected from the DPC. It will be necessary to educate staff regarding the importance of DPC for efficient implementation of this system. It is also important to further explore factors that will increase the QOL of medical workers and hospital income.