Bottom-Up Approach to Establish Coordination Mechanisms for Disaster Preparedness Among Largely Private Health-Care Providers in Central Tokyo

Abstract

In Japan, despite its private-dominant and disjointed health-care system, national initiatives to coordinate various types of health-care facilities are lacking. Municipal governments manage this task with limited resources. This study describes a successful example of a bottom-up approach to create city-wide collaboration for disaster preparedness. In Minato City, located in central Tokyo, a group of physicians created a project involving a city-wide disaster medical care drill. The city Public Health Center, in charge of health-care systems including disaster medicine, helped the group to increase proponents of the project. The city-wide disaster drill started in November 2017; thereafter, the drills were held every year. Participation in drills by various health-care personnel helped establish a city-wide system for disaster medical care, coordination mechanisms among stakeholders, increased motivation among health-care personnel, and development of in-hospital systems. This approach is flexible and applicable to various forms of health-care systems in other areas.

To deal with surges in patient numbers arising from disasters and public health emergencies, which single hospitals cannot manage on their own, highly integrated and coordinated disaster medical care systems are critical. Public-dominant health-care systems require well-organized command-and-control mechanisms, and private-dominant systems require close and well-planned sector-wide partnerships. “Health care coalitions” (HCCs) in the United States are an example of partnerships among largely private health-care providers and other stakeholders. They are voluntary coordination mechanisms between hospitals, public health agencies, and emergency management agencies, supported by and invested in by the federal government. ^1,2

In Japan, similar coordination mechanisms are required for disaster preparedness because of the country’s private-dominant health-care system and frequent natural disasters, including earthquakes and floods. ^3,4 However, such mechanisms are underorganized in Japan for 2 main reasons: first, the national government has no specific initiatives or funds for this purpose, and municipal governments are in charge of disaster medical care and may allocate their own small budgets; second, a large number of small-sized private organizations provide health care throughout the country, contributing to good health-care access under the public health insurance system. However, this complicates area-wide collaborations because the organizations sometimes compete economically in the same area. ⁴

Nonetheless, a city-wide disaster medical care drill project in central Tokyo has succeeded in forming collaborations between various health-care providers and the municipal government, although it is still in the early stage of coalition development. It was initiated as a voluntary endeavor by physicians in the private sector without government funding. This case study describes the bottom-up approach of this project and demonstrates its potential for coordinating stakeholders with limited resources to prepare for disasters in health-care systems dominated by small private organizations.

Organizational Context

Minato City (Minato-ku), 1 of 23 sub-divisions (wards) in the special administrative district of central Tokyo, is located in a core business area with many commercial facilities and office complexes. It has an area of 20.37 km ² , a residential population of 259,893, and a daytime population of approximately 970,000 (as of October 1, 2020). ⁵ Like other ordinary municipalities, the 23 sub-divisions are autonomous and have their own assembly, executive branch, and elected mayor. However, their relationship with the prefectural government (the Tokyo Metropolitan Government) differs from that between other municipalities and prefectures. The Tokyo Metropolitan Government is responsible for area-wide tasks including water supply and fire services, usually undertaken by municipalities. ⁶ The Minato City Government has its own public health center, which manages and supervises health services including disaster medical care.

In Japan, municipalities mainly take charge of disaster management in their jurisdictions under the Basic Act on Disaster Management (Table 1). Guided by national and prefectural policies, municipalities develop community disaster management plans, which include disaster medical care. In Tokyo, the Metropolitan Regional Disaster Management Plan and Disaster Medical Care Guidelines stipulate the roles of health-care providers and municipal governments. All hospitals are assigned roles for disasters, and municipalities should have their own community disaster management plans to prepare shelters and first-aid stations and coordinate with hospitals. In Minato City, the Coordination Council for Disaster Medical Care—consisting of representatives from the city government, public health center, police, fire services, and health-care providers—advises on specific disaster medical care plans. ^7,8 The Council includes municipal disaster medical care coordinators, who are appointed from among physicians working in the city to support the public health center to manage disaster medical care. The Council has a Hospital Section sub-committee that focuses on collaborations and coordination between hospitals. The Minato Public Health Center serves as the headquarters for disaster medical care management and coordination. In Tokyo, area-wide issues regarding disaster medical care, which cannot be resolved within each municipality, are managed at the medical district level, consisting of several municipalities. Minato City belongs to the Central Tokyo Medical District, which has a Regional Coordination Council for Disaster.

Table 1. Framework and organizations for disaster management in Minato City

Note: “Hospitals” are defined as medical care facilities with 20 or more beds.

The municipal disaster medical systems should function in collaboration with the nationwide disaster management system that allocates resources to disaster-affected areas (Table 2). ^9,10 The municipal disaster medical care coordinators, in cooperation with the regional and metropolitan coordinators, allocate the ward’s remaining medical resources and external assistance. The disaster base hospitals designated throughout the country to lead medical care in disaster-affected areas also provide assistance to affected areas despite being situated in an unaffected area. In large-scale disasters, various assistance teams enter the affected area from unaffected areas throughout the country. For example, disaster medical assistance teams (DMATs) are dispatched from disaster base hospitals. In addition, a wider-regional air transport system is established to mitigate the excess medical demands in affected areas; critical patients are transported to disaster base hospitals outside the affected area. The Emergency Medical Information System (EMIS) is an Internet-based system that collects and shares disaster-related information nationwide; it gathers information such as the available medical resources and demands as well as DMAT activities in the affected areas to expedite the aforementioned coordination.

Table 2. Nationwide disaster medical system

Abbreviations: DMAT, Disaster Medical Assistance Team; MHLW, Ministry of Health, Labour and Welfare; SCU, staging care unit.

Problem

The Great East Japan Earthquake that took place in March 2011, and subsequent consecutive disasters that struck Japan, triggered the enhancement of disaster management plans, including medical care. The 2012 and 2014 amendments of the Tokyo Metropolitan Regional Disaster Management Plan and subsequent Tokyo Metropolitan Disaster Medical Care Guidelines ⁷ specified the municipalities’ responsibilities and assigned roles to all hospitals depending on their capacities and characteristics. The 2012 amendment introduced “First-aid stations” that should be set up adjacent to hospitals to provide triage and first aid, in addition to medical care stations in disaster shelters. It also introduced municipality level disaster medical care coordinators. On the advice of the disaster medical care coordinators, municipalities should delegate station management to the hospitals and coordinate their functions. Materializing these specifications requires negotiation, collaboration, and agreement with stakeholders, as well as effective disaster drills.

When the city-wide drill project was proposed, Minato City was yet to effectively administer the responsibilities specified by the regional and community disaster management plans and guidelines, with many issues still to be addressed. The hospitals in the city, except for the disaster base hospitals, had no experience, plans, or exercises to manage the first-aid stations. Thus, initial requirements to substantiate the disaster management plans involved negotiations with the hospitals for setting up of the stations adjacent to or even in the hospital premises; securing resources for the station management, such as tents, equipment, and drugs; developing concrete plans for the station management; and conducting practical drills. Particularly important were triage and coordination among hospitals to transfer patients to appropriate hospitals.

In addition, mechanisms to coordinate disaster medical system had not existed in Minato City. City-wide large-scale disaster management drills had not been conducted to assess and improve the logistics of resources and coordination abilities among stakeholders; however, there had been small-scale communication exercises among disaster base hospitals and the Minato Public Health Center, or in-hospital management training in individual hospitals. The Tokyo Metropolitan government had conducted large-scale disaster management drills every year, which experts from Minato City also attended. However, such drills were just an exhibition of equipment and skills without practical exercises in each of the organizations and coordination among them. No collaboration or communication had existed between hospitals and surrounding facilities or communities that may have had medical needs and could provide disaster management support.

Solution

Leading Stakeholders

Physicians involved in disaster medical care planning in Minato City (physicians in tertiary care hospitals and directors of city medical associations, who were members of the Coordination Council) shared their perception that effective collaboration mechanisms and disaster drills were lacking and that disaster plans needed to be realized to address issues revealed in the frequent disasters of the early 2010s. They were well acquainted with each other as most of them were emergency physicians who had attended local meetings related to emergency medical care, which facilitated their collaboration. They found opportunities to discuss the future directions of the city’s disaster management and formed a team to propose a project plan for city-wide disaster medical care drills.

The director of the Minato Public Health Center agreed with the physicians’ perceptions, accepted the proposal, and supported the team. The Public Health Center provided a venue for preparatory meetings that took place every 1 or 2 mo, recorded meeting minutes, and provided advice so that the project suited the city’s Minato Disaster Management Plan. This support greatly assisted the project team, which started as a small group consisting of a few physicians, and gradually expanded to include proponents from various health-care facilities.

Establishing the Hospital Section

To respond to the specifications in the Tokyo Metropolitan Disaster Medical Care Guidelines regarding the roles of hospitals and to emphasize their coordination mechanisms in the provision of disaster medical care, Minato City established the Hospital Section sub-committee under its Coordination Council for Disaster Medical Care in 2015. The Hospital Section facilitated the discussion about city-wide disaster medical care drills.

City-Wide Joint Disaster Medical Care Drills

In 2016, the physicians’ project team started to develop a city-wide disaster medical care drill that involved all health-care providers in the city. To facilitate participation from various types of hospitals, they limited the drill contents to essential practices, such as setting up a first-aid station and triage, and communication exercises. Their first goal was to create a city-wide joint drill that covered all health facilities and personnel in the city to establish coordination mechanisms, and to gradually raise the level of practice in the drill to develop each hospital’s abilities. To include not only hospital staff but also health-care personnel in their private practices, the project integrated local medical, dental, and pharmaceutical associations (as most private practitioners belonged to such organizations).

The first city-wide joint disaster medical care drill was held in November 2017. Subsequently, it was held every year until and including 2019, and was canceled in 2020 due to the novel coronavirus pandemic (Table 3). The drills mainly consisted of setting up first-aid stations, triage exercises, communication exercises, and operation tests of facilities and equipment in the participating hospitals. The medical, dental, and pharmaceutical associations dispatched their members to the hospitals to support the management of the stations, particularly the triage, and the hospitals issued temporary staff IDs for them to expedite their activities in the hospitals. The dispatch destinations of the medical association members changed every year so that they could observe activities in various hospitals. Pharmaceutical associations conducted drug dispensary exercises in a hospital in 2019. The number of participants increased and the drill contents progressed year by year, with all hospitals participating in 2019. In 2018, interhospital patient transfer exercises were conducted, and in 2019, a drug dispensary appeared for the first time in 1 venue, and digital radio apparatus was introduced.

Table 3. City-wide joint disaster medical care drills in Minato City

^a The total number of participants included those from outside Minato City because this was a joint program with Tokyo Metropolis and Chuo City.

^b One of the 13 hospitals discontinued their practice.

^c The public health center distributed lights and generators.

^d Digital radio apparatus was introduced in 2019.

Agreement Between the City Government and Hospitals

Reflecting the coordination mechanisms and collaborations among stakeholders developed over the past few years, the city government and all hospitals in Minato City concluded an agreement regarding the management of first-aid stations. According to this agreement, the Minato Public Health Center would allocate necessary resources to all hospitals to facilitate prompt establishment of the first-aid stations after the disaster base hospital had already received the resource allocation. The resources included tents, lights, generators, and drugs. Hospitals were expected to store and maintain the allocated resources in their premises to manage first-aid stations. It was also agreed that the hospitals could set up the stations based on their own judgment without waiting for instructions from the Public Health Center (ordinarily, instructions from the Public Health Center were required before the agreement).

Obstacles to Be Overcome

Some obstacles had to be overcome to achieve these collaborations. As most hospital staff were indifferent to disaster preparedness, which is not directly related to their daily tasks, their support for the drills was minimal at the beginning. Some of them (particularly nurses) participated in the drills as part of their duties; thus, shift work scheduling became irregular and extra payments were made for overtime work with respect to the night-time drills. Ensuring the participation of all hospitals requires very careful scheduling. As some of the hospital directors were reluctant to agree with the city government, the Public Health Center director visited every hospital to discuss disaster preparedness with them and to persuade them to participate.

Outputs

Collaborations in the city-wide joint disaster medical care drills have yielded various effects. Opinions about the effects of the Coordination Council members (the authors of this study) were summarized and categorized (Supplementary Material). The indicted effects were summarized into 28 items, rated by the council members based on their importance, and categorized into 4 groups: city-wide system development, coordination mechanisms among the stakeholders, increased awareness and motivations, and development of in-hospital system and manual (Table 4). Of these effects, those that were highly rated (mean scores of 4 points or higher) were related to city-wide system development and collaboration among the stakeholders, including the agreement between the city government and the hospitals. Although not highly rated, effects that are beneficial to the expansion of collaboration to nonhealth sectors or nondisaster issues were also indicated.

Table 4. Effects of the collaborations and joint disaster medical care drills in Minato City

Abbreviations: COVID-19, coronavirus disease 2019; EMIS, Emergency Medical Information System.

^a An information sharing and communication tool to support implementation of business continuity plans for crisis management.

The drills could identify various practical issues that need to be addressed. Some hospitals require reconsideration of venue arrangements for first-aid stations and drug dispensaries (location, layout, and access routes). In particular, hospitals with small land areas should carefully plan the location of triage and waiting zones that should accommodate a large number of people. Different considerations are required for different disaster occurrence timing (staff availability is low at night and on holidays; heat and cold weather should be considered in the venue arrangements). The need for resources has become clear (more radio apparatus, lights, helmets, and reporting forms are needed) and improvements in drill contents have been suggested (skill training, role clarification, and reallocation; procurement of human and material resources; standardization of drill contents; consideration of electric, water, or system failure; manual development; enhancing communication and collaboration among hospitals; and consideration of continuing usual tasks).

Discussion

Keys to Success

Collaborative activities to prepare for disaster medical care in Minato City have successfully been voluntarily formed without governmental initiatives or funding, although further development is required. This success is attributable to the bottom-up approach led by a group of physicians engaged in emergency and disaster medicine and clinical practices ranging from the primary to tertiary level. Ideas about coordination mechanisms in disasters took shape as a city-wide drill plan reflecting the group’s knowledge and know-how fostered by their varied clinical experiences. This led to practical and feasible (let us start from where we can) rather than idealistic and dogmatic (disaster medicine should be like this) exercise programs so that various types of health-care facilities (from primary to tertiary and from acute to chronic care) could participate.

Another key to success is close collaboration between physicians and the Minato Public Health Center staff. While the physicians led the actual planning of the drills (determining the drill contents and scheduling), the Public Health Center provided substantial support for the planning procedures (providing venues, taking meeting minutes, and advising regarding government policies). In addition, support from the Public Health Centers contributed to the expansion of participation in drills. The involvement of the Public Health Center somewhat legitimized the planning activities, and collaboration efforts were finally realized by a formal agreement between hospitals and the city government.

Applicability Outside Organizations

Due to its flexibility, the bottom-up approach adopted in Minato City is applicable to various forms of health-care systems in other regions. Most municipalities in Japan have health-care systems largely served by various compositions of small- to middle-sized private sectors mixed with the public sector. ⁴ The top-down approach based on a publicly established strict command system would not work as each municipality may require its own form of collaboration while maintaining the autonomy of the private sector. In addition, the fact that strong initiatives or large funding support are unnecessary makes it affordable for small municipalities with scarce resources.

Challenges

Collaboration activities and joint drills are still in an early stage, and there are many challenges that need to be addressed (Table 5). First, the disaster drills conducted so far did not include sufficient exercises that took into account those with special needs (elderly people; those living alone, with disabilities, and receiving home medical care; dialysis patients; expectant mothers; and infants), who tend to have difficulties in accessing medical care during disasters. ¹¹ The latest drill included private physicians providing home medical care to such people, which informed the drill planning team of the locations and conditions of such people. Integrating such information into Minato City’s disaster planning would enable the development of specific evacuation and care plans for those with special needs, the number of whom is rapidly increasing in the Japanese super-aged society.

Table 5. Future challenge

Second, sector-wide collaborations are still insufficient for a wider impact on disaster management. So far, the drills did not involve collaboration with clinics not affiliated with the Medical Association or with the Judo Therapist (Japanese traditional osteopathists/bonesetters) Association due to competing interests among the stakeholders, and did not cover facilities such as nursing homes because the main focus of the drills was the management of first-aid stations. These organizations may be integrated in future activities. Collaborations with surrounding commercial facilities, business entities, and schools should be developed given the large number of workers, customers, and students accommodated in these facilities in the daytime. During disasters, many of these people would stay in these facilities owing to difficulties in returning home or their medical needs. ¹² Disaster drills that involve first aid training and dispatch of medical teams to these facilities may enable them to accommodate minor cases after triage at the first-aid stations.

To address area-wide medical needs that may exceed the available resources within the city, collaborations and communications with medical facilities and personnel outside the city, including those in remote areas, should be strengthened in the management plans and drills. During a large-scale earthquake, more injured victims would come into Minato City from municipalities outside than from those within the medical district. Excess demands should be managed through area-wide patient transfer, including wider-regional air transport to remote unaffected areas, and accepting external assistance teams (e.g., DMATs). ^9,10 Additionally, training that involves sharing of information through the EMIS and simulation of area-wide transfer should be included.

Third, disaster management plans and drills should be expanded to incorporate regional business continuity management. ¹³ The current Minato City disaster medical care system still seems to be an assortment of each hospital’s individual functions with great variations, and a lack of strong referral functions in disaster situations. We completed the first goal of doing something together. Each organization should specify its roles and improve its abilities and then, they should work in coordinated ways. To this end, inter-hospital variations in ability should be minimized, role allocation should be clearly described, and headquarter functions should be strengthened. Therefore, drill contents should be converted from “independently determined and conducted” to be more coordinated and standardized.

Conclusions

The collaborations and coordination mechanisms to prepare for disaster medical care in Minato City have been formed based on physicians’ voluntary endeavors without governmental initiatives or funding, although the mechanisms are still in an early stage and many challenges have to be addressed. The bottom-up approach adopted in Minato City is flexible and may be applicable to various forms of health-care systems in other areas.