Table 1 Framework to measure incremental activity for patient safety and infection control

1.

Staff assignment

Staff assigned to the division of patient safety or infection control to be in charge of their activities

2.

Meetings and conferences

Meetings and conferences held for patient safety and infection control (e.g. supreme decision-making board committee, medical accident investigation committee, regular staff meetings, infection control committee, etc.)

3.

Internal review and walk rounds

Internal check for patient safety or infection control (e.g. review for adherence to manual, clinical chart review, and clinical conferences, etc.)

4.

Internal education and training

Education and training program set up and run inside hospitals (e.g. orientation for new comers, seminars of patient safety or infection control, etc.)

5.

External education and training

Education and training program set up and run outside hospitals (e.g. seminars conducted by government and professional organization, etc.)

6.

Standard manual development

Standardization of processes 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.)

7.

Incident reporting

Data collection/analysis as well as measurements of incident reports, adverse events and near misses to assure patient safety

8.

External audit

Third-party evaluation to continuously improve the safety and quality of care (e.g. the Japan Council for Quality Health Care, the International Organization for Standardization, etc.)

9.

Maintenance of medical equipment

Maintenance to prevent medical accidents (e.g. check and repair of medical equipment, etc.)

10.

Management of medications

Management to prevent medical accidents (e.g. medication history management, drug information service, and dispensing instruction, etc.)

11.

Infection surveillance

Data collection, analysis, and measurements of in-hospital infection (e.g. review of medical charts and bacteriologic examination of surgical site infections and catheter-related infections, etc.)

12.

Other activities

Other activities related to patient safety and infection control and not categorized as above activities (e.g. campaigns, issues of public relations, newspapers related patient safety or infection control, etc)