# Clinical Indicator Implementation in Japanese Public Hospitals: A Comparative Study of the 2016 and 2024 Trends After the COVID-19 Pandemic

## TL;DR

This study examines how Japanese public hospitals have adopted clinical indicators before and after the pandemic, showing progress but also disparities.

## Contribution

The study provides updated evidence on clinical indicator adoption in Japan using Donabedian’s model and highlights persistent implementation gaps.

## Key findings

- Clinical indicator adoption increased from 42.4% in 2016 to 58.5% in 2024.
- Large hospitals were more likely to implement clinical indicators than small and medium hospitals.
- Structural indicators remained underutilized, with less than 15% adoption.

## Abstract

Aim

This study investigates the adoption and implementation of clinical indicators in Japanese public hospitals, focusing on changes since the coronavirus disease 2019 (COVID-19) pandemic and utilizing Donabedian’s triadic model (structure, process, outcome).

Methods

A nationwide postal survey was conducted targeting 848 municipal hospitals with ≥20 beds in Japan. The survey explored clinical indicator usage, categorized by Donabedian’s framework. Hospitals were classified based on size to evaluate disparities in indicator adoption. Data were analyzed to compare findings from the 2024 survey with a similar 2016 survey. Questionnaires were mailed at the end of September 2024. Survey participants were provided with an extended deadline of December 16, 2024, which was one month after the original deadline.

Results

As of December 17, 2024, the response rate was 15.7% (133 hospitals), with 130 valid responses. Clinical indicator adoption increased from 42.4% (97) (2016) to 58.5% (76) (2024). Large hospitals were more likely to implement clinical indicators (59 [88.1%]) than small and medium hospitals (17 [27.0%]). Frequently used indicators included average hospitalization duration, bed utilization rates, and clinical pathway coverage. Each structural indicator remained underutilized, with <15% of hospitals reporting their use.

Conclusion

The findings highlight progress in clinical indicator adoption, particularly in large hospitals. However, significant disparities persist between hospital sizes. As the pandemic subsides, it remains essential to continue improving hospital management practices, including clinical indicator use, in preparation for future infectious disease outbreaks. The three-way model classification for medical evaluation is renowned, but the percentage use of structural indicators has not exceeded 15%, and the implementation status is not as advanced as that of process and outcome indicators. Our results are significant as they verify the explanatory power of the three-way model for medical care based on Japanese data.