Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

Effects of Incorporated Psychiatric Institutions’ Internal andExternal Control on Their Local Distributions and HierarchicalFormation: Case of Osaka
Masahiko Takaya

Faculty of Medicine, Kindai University, Japan
Association for Research on NPOBP E-mail: takaya@med.kindai.ac.jp
Abstract
Medical institutions in Japan can be classified as either public or private, with both being
basically nonprofit organizations. However, most private medical institutions are incorporated
and have equity; in this sense, they operate as for-profit organizations. Moreover, their data are
not freely disclosed, making their internal controls too difficult to investigate. On the other hand,
the Ministry of Health, Labour and Welfare control the public medical and care system either
directly or indirectly; for example, the Ministry regularly revises the medical-fee system.
However, it is difficult to decide whether this system works well or not because the system of
medical institutions is too complex. To investigate a simpler model, this study examined private
psychiatric hospitals. This study aimed to examine the local competitiveness of incorporated
psychiatric hospitals, in order to reveal whether internal and external control works well or not.
In this study, 30 out of 49 private psychiatric hospitals listed on the homepage of Osaka
Association of Psychiatric Hospitals were investigated. The selected sample represents“dedicated” psychiatric hospitals, offering only psychiatric beds. “Having a license to charge a
psychiatric emergency hospitalization fee” is an indicator of external control, and can be also
considered as an indicator of clinical activity in each hospital. Distribution of psychiatric beds
as well as of hospitals with the license was examined in each medical area. This study concluded
that the uneven distribution of psychiatric beds as well as psychiatric emergency hospitals andthe hierarchical formation of the incorporated psychiatric hospitals system can be observed.
Keywords
Incorporated medical institution, Psychiatric hospital, Control, Hierarchy, Distribution, Medical
area(1) Introduction

respectively,

1. Equity and limitedly disclosed information

hospitals and incorporated medical clinics total

The total number of medical hospitals and

5,721 and 39,455, respectively, as of the 1st ofclinics in Japan is 8,493 and 100,461,
1

while

incorporated

medicalJournal of Japanese Management Vol.1, No.1, November 2016

October, 20141.

ISSN 2189-9592

hospital that can be accessed by using registries

Most incorporated medical institutions in(Toukibo in Japanese) are too limited. The

Japan are known to have equity. Typicalnumber of the members of the board of directors

incorporated medical institutions are called(Riji in Japanese) within an incorporated

Iryou-houjin in Japanese. Kawabuchi reported
that in 2014, of the total 49,889 Iryou-houjins,

medical institution is decided by law 3 . There

the number of incorporated foundations was

directors, and at least one auditor (Kanji in391, while

incorporated

Japanese). Registries only need to include theassociations was 49,498. Of the 49,498

chief’s (of the board of directors) (Riji-chou inincorporated associations, 41,476 associations

Japanese) name but not those of all thehave equity, while the remaining 8,022 do not2.

members of the board of directors4. Registries

That is, 83% (41,476/49,889) of incorporated

are not required to state whether the hospital is

medical institutions own equity (Figure 1).

an association or a foundation. Moreover, when

However, data that would enable similar

an incorporated hospital is an association, its

analysis of incorporated psychiatric institutions,

equity status is not disclosed in the registry.

whether hospitals or clinics, are not available;

Similar to small and medium-sized enterprises,

thus, it is not possible to compare equity status

incorporated hospitals pose the problem ofamong other types of institutions.

limited data.

thenumber ofmust be three or more members of the board of

2. Public roles of private psychiatric medical
institutions
In this study, the term “private” is definedas “non-public” (in a broad sense).
Privatepsychiatricinstitutions

play

important roles in Japan. The total number ofpsychiatric beds in Japan is 338,174, with
267,578 of those operated by incorporated

Figure 1. Incorporated medical institutions in Japan

psychiatric hospitals. Therefore, incorporated

Source: This figure is created by the author based on

psychiatric hospitals represent 79% of all(Kawabuchi , 2014, p.43)

psychiatric

beds.

The

total

numberofpsychiatric hospitals was 1,067, with 912 of

In this study, incorporated hospitals andthemincorporated psychiatric hospitals are definedincorporated

psychiatrichospitals.

Therefore, 85% of psychiatric hospitals areas “hospitals” and “psychiatric hospitals” which

incorporated

belong to incorporated medical institutions,

psychiatrichospitals.

These

statistical data are accurate as of the 1st ofrespectively. The data on each incorporated

2 Kawabuchi, 2014, pp.43-44

1 Toukei-Hyou (in Japanese), the Ministry of Health,

3 Iryou Hou in Japanese:

Labor and Welfare:
http://www.mhlw.go.jp/toukei/saikin/hw/iryosd/14/dl/03_
toukei.pdf

http://law.e-gov.go.jp/htmldata/S23/S23HO205.html

4 Kumiai-tou Touki Rei (in Japansese) : http://law.e-

gov.go.jp/htmldata/S39/S39SE029.html

2

Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

October, 2014, according to the Ministry of

hospital is allowed depends on the total number

Health, Labour and Welfare5.

of beds in the area in which the hospital is

Whether incorporated or not, hospitals

located. Each hospital gets its share inproviding psychiatric care in Japan must obey

competition with the other hospitals in the same

the Act on Mental Health and Welfare for thearea.

Mentally Disabled (Seishin Hoken Fukushi

completely free, and strong vested interests

Hou in Japanese), which was enacted in 1995.

may exist.

However,thiscompetition

is

not

Several laws mostly protecting human rights ofpsychiatric patients enacted after the end of the

4. Thecompetitive

systemamong

Second World War. These laws were responses

incorporated psychiatric hospitals

to major violations of the human rights ofMedical fees for treatment covered bypsychiatric patients. There have been several

health insurance are the remit of the Ministry

revisions to this legislation over the years,of Health, Labor and Welfare in Japan.

leading it to evolve into the Act on Mental

Therefore, medical fees (excluding fees for

Health and Welfare for the Mentally Disabled

medical treatment not covered by health(Seishin Hoken Fukushi Hou).

insurance) are subject to a de facto official price,

byThus, although psychiatric care is governed

and in fact can be policy variables. The

Japan’s

government is able to run and improve apublicdepartments,

most

psychiatric-hospital treatment takes place inprivatehospitals,

incorporated

most

psychiatric

of

which

are

hospitals.

This

medical policy by controlling the variables.
Medicaltreatments

andtechnologies

performed in general hospitals are generally

presents a paradox.

more complex than those in psychiatrichospitals. Therefore, the medical-fee system of

3. Second medical areas in Japan
In

Japan,

344

in

2013;

generalhospitals

is

more

difficultformedicalnonprofessionals to understand. On the otheradministration areas called “second medical

hand, the medical-fee system in psychiatricareas” 6have been established to provide

hospitals is easier to understand because thesegeneral hospital treatment, which is based on

hospitals’ functions and abilities are simpler at

the Medical Care Act 7 . In Osaka prefecture,a glance.

eight second medical areas were established in

Therefore, to investigate the governance of

20158. Under the act, the number of hospitalincorporated hospitals, psychiatric hospitals

beds in each area is controlled and reviewed

were selected due to the narrower range ofevery five years by each prefectural governor.

medicalThe same is also true for psychiatric hospitalcompared with general hospitals9.

bed numbers. The number of beds that eachskills andtechnologies involved

However, medical care in psychiatric
7 Iryou Hou (in Japanese): http://law.e-

5 Toukei-Hyou (in Japanese)

gov.go.jp/htmldata/S23/S23HO205.html

http://www.mhlw.go.jp/toukei/saikin/hw/iryosd/14/dl/03_
toukei.pdf
6 Iseikyoku (in Japanese), the Ministry of Health, Laborand Welfare:
http://www.mlit.go.jp/common/001086652.pdf

8 Osaka Prefectural Government:

http://www.pref.osaka.lg.jp/attach/2502/00118050/02_16_02_fuikiban_02_syou_03_setsu.pdf
9 Takaya, 2016, p.41

3

Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

hospitals has been differentiated and gradedFujioka described Japan’s medical-institution

these days. For example, the system of needing

governance models as reflecting two influences.

a license to charge a psychiatric emergency

One is the “clinical governance” model of thehospitalization fee was established in the 2002

United Kingdom (UK), and the other is therevision of medical fees10.

“hospital governance” model of the United

HospitaltheStates (USA). The former focuses mainly on

certification system of specialists) have evolved

offering safe and high-quality health care,

under the control of the Ministry of Health,whereas the latter focuses on a governance style

Labor and Welfare since the Meiji government,akin

a process that was discussed in terms of generalorganizations 14 . Additionally, Fujioka referred

hospitals11. Now, national and public hospitals

to the internal control of medical organizations

playclinicalas risk-based by management, and opined thattreatment, undertaking medical research, andmanagement solely by family groups (relatives)offering

contrast,

should be abolished in medical institutions 15 .

psychiatric hospital systems have historically

However, governance theories such as thatdiffered from those of general hospitals.

espoused by Fujioka 16 are confusing because

Therefore, the system of competition among

they fail to distinguish between public andincorporated

seems

private hospitals when discussing governance,

different from that among general hospitals.

including internal and external sources ofHowever, investigation of the former could offer

control. For example, Fujioka did not classify

insight into the latter.

hospitals byleadingsystemsroles

specialistin(including

providingtraining.

psychiatricIn

hospitals

to

those

utilizedtypebyfor-profit(e.g., general,

specialfunctioning)17. Matsubara, et al. discussed ideal
5. Literature

Reviewofgovernanceofgovernance styles of incorporated medical

incorporated medical institutions

institutions in Japan. However, they used the

5.1. Governance model of hospitals

term “public interest” in an ambiguous way

When investigating the governance of

without precisely defining it; they insisted onincorporated hospitals, there are two theoreticalthe necessity of governance only in incorporated

approaches: the governance theory for nonprofit

medical institutions18

organizations and the governance theory for

Most

Japaneseincorporated

medicalmedical institutions. The former holds that no

institutions are managed by family groups

standard governance model fits all nonprofit(relatives), and information about them isorganizations 12 . The latter is a theory

closely held, thus frustrating attempts at data

specifically tailored to medical institutions.

collection.

Several previous studies about governanceThismanagement

of

may

make

studiesincorporatedof

medicalof medical organization were reviewed 13 .

institutions too difficult. On the other hand,

10

14 Fujioka, 2013, pp.151-166

On the psychiatric Emergency Care system:
http://www.mhlw.go.jp/shingi/2009/03/dl/s0326-8c.pdf
11 Takaya, 2015, pp.108-120
12 Hotta, 2012, p.787
13 Fujioka, 2013, pp.167-197

15 Fujioka, 2013, pp.167-181
16 Fujioka, 2013, pp.151-198
17 Fujioka, 2013, pp.167-197
18 Matsubara, et al. 2004, pp. 4-8.

4

Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

case studies of non-incorporated medical

charge a psychiatric emergency hospitalization

institutions

fee, (2) a specialist psychiatry training facility

haveexamined

successful

innovations by way of internal control systems

authorized

implemented in hospitals19.

by

the

Japanese

SocietyofPsychiatry and Neurology (JSPN), and (3)The Medical Care Act (Iryou Hou in

authorization from the Japan Council for

Japanese), which was established in 1948, has

Quality Health Care (JCQHC). The first

been

represents the hospital’s clinical competence22.

improved

severaltimes,

includingestablishment of rules that should be applied toThe

incorporated medical institutions; however,competence of the hospital’s specialists. The

these were later revised for the sake of “public

third represents overall hospital competence23.

interest” in Japanese medical systems20. As a

It is not impossible to conclude that theresult, even now, information on incorporated

separation of ownership and management inmedical institutions is not sufficiently disclosed,

incorporated psychiatric hospitals bears a

as mentioned above.

relation to any of these three activities24. The

Though the discussion on whether non-secondrepresents

theeducational

reasons for this can be thought of as follows.

profit medical institutions are better has beenFirst, thelong-running, no clear conclusion has emerged

management

in a theoretical sense. This is partly because themedical institutions may be only nominal and,term “public interest” cannot be defined strictlyin fact, cannot be performed. Second, hospitalin theoretical economics21. However, in Japan,

activities might be influenced by the inter-medical institutions need to be officially non-relationship of administrative units, which

profit, whether or not they are incorporated. As

helps establish medical facilities or controls

mentioned above, most medical institutions intheir activities and competence25.

Japan

are

substantiallyseparation of ownership andofincorporated

psychiatricincorporated

enterprises. The separation of ownership and6. Aim of this study

management is not realized for many small andAs mentioned earlier, the activities andmedium-sized institutions, which is also true ofcompetences

incorporated psychiatric medical institutions.

hospitals cannot be determined based on the

5.2. Relationship between governance andseparation of ownership and management. This

activities of private psychiatric hospitals

suggests that other factors may influence

Takayacompetitivenessinvestigatedtherelationshipbetween the separation of ownership andofincorporated

among

psychiatricincorporated

psychiatric hospitals in Japan.

management of the incorporated psychiatricThis study investigated private psychiatric

medical institutions in Osaka, Japan, and their

hospitals in Osaka prefecture, Japan. In theinstitutional activities by

examining thefirst phase, the private psychiatric hospitals

possession of three elements: (1) a license towere surveyed, most of which are incorporated

19 Matsuo, 2009, pp.1-223

22 Takaya, 2016, pp.42-47
23 Takaya, 2016, pp.42

20 Iryou Hou (in Japanese): http://law.e-

24 Takaya, 2016, pp.46-47

gov.go.jp/htmldata/S23/S23HO205.html

25 Takaya, 2016, pp.40-49

21 Takaya, 2015, pp.108-109

5

Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

hospitals. In the second phase, a sample ofdirector of the hospital (Byuoin-chou in“dedicated” psychiatric hospitals was selected,

Japanese) is the same person,” “the chief of theand their local distribution and hierarchicalboard of directors is thought to be a relative ofstructures were investigated, using cross-the director of the hospital,” and “the chief of thesectional data.

board of directors is not the same as, nor is arelative of the director of the hospital.”(2) Empirical analysis“Psychiatric emergency beds” in Table 1 is the

In this study, statistical analysis wasnumbers of beds for which a psychiatricperformed using the software jmp10 (SASemergency fee can be charged (approved by a

Institute Inc., Cary, NC, USA).

regulatory agency). This approval represents
psychiatric

1. Private psychiatric hospitals in Osaka,Japan
Psychiatrichospitals’ clinicalcompetence) 27 .

activity(or“Approval year” indicates theyear when each hospital was licensed to collecthospitals

in

Japan

are

the psychiatric emergency fee. “Opening year” isgenerally classified as in Figure 2, according tochiefly based on the homepage of each hospital.

their types of establishers.

Cases when “the opening year” cannot be foundare denoted by a “ * ” symbol.
Hospitals whose “Governance type” isclassified into “B” were excluded from this study
because the separation of ownership andmanagement is unclear even in a nominal sense.
Hospitals 16 and 17 are run by the same chief ofFigure 2. Types of psychiatric hospitals in Japan.

the board of directors, as are Hospitals 18-20. In

Source: This Figure is modified from the original

Hospitals 16 and 18, the chief of the board ofversion shown in the website;

directors holds the director of the hospital.

http://www.mhlw.go.jp/toukei/saikin/hw/iryosd/14/dl/

Therefore, Hospitals 17, 19, and 20 were

03_toukei.pdf

removed from the analysis to reduce complexity.
We

The website of the Osaka Association of
Psychiatric Hospitals

usually

maintainthephrase“psychiatric hospitals.” but psychiatric hospitals

lists 49 private

are not precisely defined. Some general

psychiatric hospitals as members (Table 1). In

hospitals have psychiatric beds, and some

Table 1, the column “Name of hospital

hospitals, for example Hospital 48 in Table 1,(Abbreviation)”alphabetical

are thought to be “psychiatric hospitals” evenabbreviations of corresponding hospital names

though they can be classified as “generalin Japanese.

hospitals.” Therefore, “psychiatric hospitals” are

26

shows

The terms A, B, and C in “governance type”

defined in this empirical analysis as hospitals

mean, respectively, “the chief of the board ofthat provide psychiatric beds only. According todirectors (Riji-chou in Japanese) and thethis definition, 13 hospitals in Table 1 were ex-

26 http://www.daiseikyo.or.jp/

27 Takaya, 2016, pp.42-47

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Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

Table 1. Private psychiatric hospitals in Osaka, Japan
NumberName of hospital(Abbreviation)

Governancetype

Opening
year

Regular doctor

Psychiatricbeds

Recuperation
beds

Beds forgeneralpatients

Total beds

Psychiatricemergency
beds

Approval year

1

Mizuma

A

1959

11

541

0

0

541

0

*

2

Kijima

A

1963

13

492

0

0

492

0

*

3

Yoshimura

A

1976

6

222

0

0

222

0

*

4

Sakane

A

1965

3

150

0

0

150

0

*

5

Tamenaga

A

1965

7

266

0

50

316

0

*

6

Watanabe

A

1965

9

336

100

0

436

0

*

7

Keihan

A

1954

9

306

0

0

306

0

*

8

Shichiyama

A

1599

13

640

0

0

640

48

2011

9

Neyagawa

A

1965

10

267

0

0

267

60

2014

10

Kaizukachuou

A

*

9

406

0

0

406

0

*

11

Orenji

A

1965

3

240

0

0

240

0

*

12

Kumeda

A

1962

9

494

0

0

494

0

*

13

Osakasayama

A

1966

6

279

0

0

279

0

*

14

Kosaka

A

1948

17

537

0

0

537

0

*

15

Kouai

A

1964

10

221

0

0

221

0

*

16

Sawa

A

1953

30

455

0

0

455

114

2005

17

Hokuto

C

*

8

50

0

0

50

50

2008

18

Aobaoka

A

1986

16

357

270

54

681

0

*

19

Aino

C

1965

45

600

144

225

969

0

*

20

Ainohanazono

C

1984

13

606

0

0

606

0

*

21

Esaka

B

1965

8

360

0

0

360

0

*

22

Ibaragi

B

1952

8

350

0

0

350

0

*

23

Kokubu

B

1961

9

201

0

0

201

48

2008

24

Hanna

B

1967

5

213

48

0

261

0

*

25

Kanaokachuou

B

*

10

486

0

0

486

0

*

26

Shinseikai

B

1981

3

148

0

0

148

0

*

27

Kansaisanatoriumu

C

1968

2

192

0

0

192

0

*

28

Kansaikinen

C

1983

4

270

0

46

316

0

*

29

Sakamoto

C

1892

16

546

0

0

546

0

*

30

Hanwaizumi

C

1965

11

354

90

0

444

0

*

31

Mikunigaoka

C

1960

5

144

0

0

144

0

*

32

Hannan

C

1956

46

690

0

0

690

168

2007

33

Kokoroa

C

*

11

450

0

0

450

0

*

34

Izumichuou

C

*

5

206

0

0

206

0

*

35

Mihara

C

1963

5

562

0

0

562

0

*

36

Higashikori

C

*

10

38

39

45

122

0

*

37

Minou

C

1960

8

345

0

0

345

0

*

38

Yao

C

1913

14

513

0

0

513

0

*

39

Kaede

C

*

4

150

0

0

150

0

*

40

Shinabuyama

C

1971

8

273

0

0

273

0

*

41

Tanpisou

C

1956

12

310

0

0

310

0

*

42

Shirai

A

1965

9

322

48

29

399

0

*

43

Kisen

C

1967

3

260

0

0

260

0

*

44

Hamadera

C

1930

20

749

0

0

749

0

*

45

Ozone

C

1956

16

557

0

0

557

0

*

46

Izumigaoka

C

1963

6

257

0

4

261

0

*

47

Shionomiya

C

1969

10

384

60

0

444

0

*

48

Asakayama

C

1922

67

948

38

185

1171

102

2008

49

Hirakataryoiku

C

1969

28

50

0

440

490

0

*

Source:(1) Table 1 is a modified version of the original table in (Takaya, 2016, p.44)(2) Statistical data are derived from the homepage of each hospital and the following websites:
Osaka Association of Psychiatric Hospitals: http://www.daiseikyo.or.jp/
Kinki Regional Bureau of Health and Welfare: https://kouseikyoku.mhlw.go.jp/kinki/Japanese Association for Emergency Psychiatry: http://www.jaep.jp/

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Journal of Japanese Management Vol.1, No.1, November 2016

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Table 2. Private Psychiatric Hospitals with Psychiatric Beds Only
NumberName of hospital(Abbreviation)

Governancetype

Medicalarea

Opening year

Regulardoctor

Psychiatricbeds

Psychiatricemergency
beds

Approval
year

Approved
training
facility

Accredited
facilitity

16

Sawa

A

A

1953

30

455

114

2005

1

1

20

Ainohanazono

C

A

1984

13

606

0

*

1

0

37

Minou

C

A

1960

8

345

0

*

1

0

45

Ozone

C

A

1956

16

557

0

*

0

0

11

Orenji

A

B

1965

3

240

0

*

0

1

15

Kouai

A

B

1964

10

221

0

*

1

0

40

Shinabuyama

C

B

1971

8

273

0

*

1

1

7

Keihan

A

C

1954

9

306

0

*

1

0

9

Neyagawa

A

C

1965

10

267

60

2014

1

1

14

Kosaka

A

D

1948

17

537

0

*

1

1

29

Sakamoto

C

D

1892

16

546

0

*

1

0

38

Yao

C

D

1913

14

513

0

*

1

0

3

Yoshimura

A

E

1976

6

222

0

*

1

0

13

Osakasayama

A

E

1966

6

279

0

*

1

0

41

Tanpisou

C

E

1956

12

310

0

*

1

1

31

Mikunigaoka

C

F

1960

5

144

0

*

1

1

32

Hannan

C

F

1956

46

690

168

2007

1

1

35

Mihara

C

F

1963

5

562

0

*

1

0

1

Mizuma

A

G

1959

11

541

0

*

1

0

2

Kijima

A

G

1963

13

492

0

*

1

1

4

Sakane

A

G

1965

3

150

0

*

0

0

8

Shichiyama

A

G

1599

13

640

48

2011

1

1

10

Kaizukachuou

A

G

*

9

406

0

*

1

0

12

kumeda

A

G

1962

9

494

0

*

0

0

27

Kansaisanatoriumu

C

G

1968

2

192

0

*

0

0

33

Kokoroa

C

G

*

11

450

0

*

1

0

34

Izumichuou

C

G

*

5

206

0

*

1

1

39

Kaede

C

G

*

4

150

0

*

1

0

43

Kisen

C

G

1967

3

260

0

*

1

0

44

Hamadera

C

G

1930

20

749

0

*

1

1

Source:(1) This table has been modified from one presented by (Takaya, 2016, p.45).
(2) Data for analysis are derived from the homepage of each hospital and the following websites:
Osaka Association of Psychiatric Hospitals: http://www.daiseikyo.or.jp/
Kinki Regional Bureau of Health and Welfare: https://kouseikyoku.mhlw.go.jp/kinki/Japanese Association for Emergency Psychiatry: http://www.jaep.jp/
Osaka Prefectural Government: http://www.pref.osaka.lg.jp/iryo/keikaku/keikaku2013to2017.html
The Japanese Society of Psychiatry and Neurology: https://www.jspn.or.jp/
Japan Council for Quality Health Care: http://jcqhc.or.jp/

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Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

cluded from the analysis. Following theseexclusions, 30 private psychiatric hospitals remained, as listed Table 2. Values of 1 and 0 for“approved training facility” mean, respectively,that the Japanese Society of Psychiatry and
Neurology approved or did not approve of eachfacility as a psychiatric specialist training
facility. Values of 1 and 0 for “accredited facility”
mean, respectively, that Japan Council for
Quality Health Care (JCQHC) has or has notaccredited the facility (hospital).
Notations “A”–“G” for “medical area” inTable 2, which correspond to those in Figure 3
and Table 3, indicate the second medical areasin Osaka, Japan, to which each hospital belongs.
Medical areas are arranged alphabetically.

Figure 3. Second Medical areas in Osaka, Japan.

Figure 3 displays Osaka’s medical areas

Source: This Figure is modified, by the author, fromgeographically.

the original version shown in the data in the website;
http://www.pref.osaka.lg.jp/iryo/keikaku/keikaku201

2. Uneven distribution of private psychiatric

3to2017.html

hospitals in terms of clinical activity
As mentioned above, Takaya pointed out

Table 3. Private hospitals licensed to charge athat it is not possible to say that having a license

psychiatric emergency hospitalization fee andtotheir medical areas

chargeapsychiatricemergency

hospitalization fee, which represents clinicalactivity, is related to either a hospital’s
governance type or the separation of ownershipand management 28 . Takaya also pointed out
that

exceptfortheMishimaandMinamikawachi medical areas, every medical
area has at least one hospital licensed to charge
a psychiatric emergency hospitali-zation fee29 .
These are shown in Figure 3 and Table 3, where

Source: This Table is modified from Tables 1 and 2,

each “hospital number” corresponds to thatand Figure 3.

used in Table 1 and Table 2. Hospitals withnumbers in parentheses in Table 3 are included

Accordingin Table 1 but not in Table 2.

to

Table

3,

an

unevendistribution of hospitals having “a license to
charge a psychiatric emergency hospitalization
29 Takaya, 2016, p.48

28 Takaya, 2016, pp.41-47

9

Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

fee” can be observed among each medical area.

estimate: －0.00485, p-value: 0.1638).

3. Relationship between the numbers of regular

5. Overall hospital competence and the number

doctors and psychiatric bedsof regular doctors or psychiatric beds

This study considers having a license to

The result of bivariate logistic regression

charge a psychiatric emergency hospitali-zation

analysis between the number of regular doctors

fee as an indicator of clinical activities in each(independent

hospital. Each hospital is assigned a specificauthorizations (dependent valuable) showed nonumber of hospital beds by each prefectural

significant correlation (parameter estimate: －government, a number that is indirectly, under

0.1183, p-value: 0.0922). Neither did the result

the control of the Ministry of Health, Labourof bivariate logistic regression analysis between

and Welfare. The allocated number of beds

the number of psychiatric beds (independent

corresponds to the area of the hospital wards.

valuable)andTherefore, the number of beds can be considered(dependentvaluable)as an initial value. On the other hand, theestimate: －0.0013, p-value: 0.5459).

valuable)

and

JCQHC
show

JCQHC

authorizations(parameter

number of regular doctors can be considered avariable in each hospital’s evolutional process

6. Competitiveness in each medical area

because each hospital can or should recruit or6.1. Clinical competence as a result of internal

control the number of the doctors in order tocontrol

improve its activity. However, Takaya foundThe relationship between clinical activity

multico-llinearity between number of beds andand number of regular doctors in private

number of regular doctors in the 30 private

psychiatric hospitals will be discussed below bypsychiatric hospitals30.

medical area, based on the data in Table 2.
Of the four hospitals in medical area A,

4. Clinical competence and the number ofhospital 16 has the most stable number ofregular doctors or psychiatric beds

doctors (30). In medical area C, Hospital 9 has

The result of bivariate logistic regression

the most stable number of doctors (10). In

analysis between the number of regular doctors

medical area F, Hospital 32 has the largest(independent valuable) and having a license tonumber of regular doctors (46), and in medical

charge a psychiatric emergency hospitalization

area G, Hospital 8 has the second highestfee (dependent valuable) showed no significant

number of regular doctors of all 12 hospitals.

correlation (parameter estimate: －0.2020, p-

These results suggest that the number ofvalue: 0.0525). Neither did the result of

regular doctors seems to have an importantbivariate logistic regression analysis between

effect on the clinical activities of each medical

the number of psychiatric beds (independentarea’s hospitals. A strict standard is imposed tovaluable) and having a license to charge aobtain a license to charge a psychiatric

psychiatricemergency

hospitalization

emergency(dependentvaluable)

show

fee

(parameter

hospitalization

fee.

This

organizational hurdle can be an indicator for the

30 Takaya, 2016, p.46

10

Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

presence of internal control as well as external

2001, p.68). As indicated in Table 1, sevencontrol; however, the mechanism of this internal

hospitals were founded in the 1950s and 23 incontrol is unclear.

the 1960s (in all, opening-year data was

6.2. Overall hospital competence as a result ofavailable for 26 hospitals). Thirty hospitals out

internal control

of 42 (71%) were founded in the 1950s or 1960s.

On the other hand, the factor “accredited

As shown in Table 2, six hospitals were foundedfacility,” which indicates JCQHC approval, canin the 1950s, and 12 hospitals in the 1960s (inbe an indicator representing the outcome ofall, opening-year data was available for 26

hospitals’ activities as well as an indicator of

hospitals) Eighteen hospitals out of 26 (69%)

external control. In Table 2, all hospitals

were founded in the 1950s or 1960s.

licensed to charge a psychiatric emergency
hospitalization fee are “accredited facilities”
according to JCQHC. However, not all hospitals
approved by JCQHC have a license to charge
psychiatricemergency

hospitalization

fee.

Therefore, a license to charge a psychiatricemergency hospitalization fee is more difficult
to get.
6.3. Relationship between internal and external
control
Official information and data for eachprivate hospital are too limited, as mentioned
above, and internal control mechanisms andgovernancetherefore,

functionswecannotarenotrevealed:

help

considerthemechanism of internal control as being
performed in a “black box”. Therefore, indicatorsfor external controls described above could be auseful tool for estimating the results of internal
controls.

Figure 4. Evolutional processes under a combination

6.4. Evolution of private psychiatric hospitals

of internal and external controls, about (1) the

Private “psychiatric hospitals” (in a broad

hospital’s clinical competence and (2) the overall

sense) in Japan were founded after the Second

hospital’s competenceWorld War perhaps in response to the public

Source: Author

demand. This can be considered “the initialstate” of the subsequent evolutionary path of

The discussions in Sections 5-1, 5-2, and 5-

the modern Japanese psychiatric hospital

3 are depicted by Figure 4. Numbers (1) and (2)system. Most private psychiatric hospitals werein Figure 4 show the systematic evolutionalfounded in the 1950s and 1960s (Kazamatsuri,

processes of private psychiatric hospitals in11

Journal of Japanese Management Vol.1, No.1, November 2016

terms of internal and external controls. From an

The

ISSN 2189-9592

first,

second,andfifth-ranking

external perspective, internal control is usually

hospitals in PB: RD in Table 4 (Hospitals 32, 16,

conducted in a “black box” region because theand 9, respectively) are licensed to charge adata and information are tightly held as

psychiatric emergency hospitalization fee. The

confidential to the institution.

PEB: PB of these hospitals is 0.24, 0.25, andOn the other hand, external control, which

0.22, respectively. Hospital 8 (Shichiyama) is an

is usually performed by regulatory agencies or

exception because it’s PED: PB is 0.075, which

the like, is exerted in the presence of available

is much lower than those of the other three

information. The term of “external control”

hospitals mentioned above.

shown in (1) and (2) in Figure 4 seems different
from “external control” defined in (Fujioka, 2013,

Table 4. Psychiatric Beds per Regular Doctor andp.197), but can be an indicator of external

Psychiatric Emergency Beds per total bed (PB/RD

control or official approval from externalratio and PED/PB ratio, respectively)

regulatory agencies or the like. In this sense, thesystem of private psychiatric hospitals has
evolved by strengthening internal controls ineach hospital, and by receiving a license to
and/orofficial

accreditationasexcellent

hospitals.
7. Hierarchical formation in terms of clinicalcompetence
Despite multiple attempts by the author,
previously disclosed data and information
related to the number of regular doctors andnumber of psychiatric beds has been elusive toretrieve, even from disclosure system of theregulatory agency. Therefore, a cross-sectional
study was conducted to investigate hierarchicalformation of the private psychiatric hospital

NumberHospitals(Abbreviation)

32
16
15
41
9
31
14
7
40
29
45
38
3
39
44
2
33
34
37
10
13
20
1
8
4
12
11
43
27
35

HannanSawa
Kouai
TanpisouNeyagawa
Mikunigaoka
KosakaKeihanShinabuyama
Sakamoto
Ozone
Yao
Yoshimura
Kaede
Hamadera
KijimaKokoroa
Izumichuou
Minou
Kaizukachuou
Osakasayama
Ainohanazono
MizumaShichiyama
SakanekumedaOrenji
Kisen
Kansaisanatoriumu
MiharaRegular PsychiatricMedicalPB/RDdoctorbeds
district
Ratio
(RD)
(PB)
F
A
B
E
C
F
D
C
B
D
A
D
E
G
G
G
G
G
A
G
E
A
G
G
G
G
B
G
G
F

46
30
10
12
10
5
17
9
8
16
16
14
6
4
20
13
11
5
8
9
6
13
11
13
3
9
3
3
2
5

690
455
221
310
267
144
537
306
273
546
557
513
222
150
749
492
450
206
345
406
279
606
541
640
150
494
240
260
192
562

15
15.2
22.1
25.8
26.7
28.8
31.6
34
34.1
34.1
34.8
36.6
37
37.5
37.5
37.8
40.9
41.2
43.1
45.2
46.5
46.6
49.2
49.2
50
54.9
80
86.7
96
112.4

Psychiatricemergency PEB/PB
beds
Ratio
(PEB)
168
114
0
0
60
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
48
0
0
0
0
0
0

0.24
0.25
0
0
0.22
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.075
0
0
0
0
0
0

Source: This Table is modified from Table 2.

system in this study.
Table 4 is modified version of Table 2, in

Hospital 8 (Shichiyama) in Table 4 isthat the PB/RD Ratio (PB:RD), which is defined

located in medical area G in Figure 3. The PB:

as psychiatric beds per regular doctor, andRD of Hospital 8 is ranked eighth among all 12

PED/PB Ratio (PEB:PB), which is defined as

hospitals in medical area G (Table 2), which

psychiatric emergency beds per psychiatric bed,means Hospital 8 seems to be an ordinary

are calculated, and the PB/RD Ratio column

private psychiatric hospital. On the other hand,rearranged in ascending order (unnecessary

Hospitals 32, 16, and 9 have top-ranked PB:RD

columns in this section are omitted).

in their respective medical areas (F, A, and C).
12

Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

In this sense, PB:RD=49.2 and PEB:PB=0.075

to the letters in Figure 3, and Tables 3 and 4. In

for Hospital 8 may be an outlier among

Table 5, the deviation values were derived based

Hospitals 32, 16, 9, and 8.

on the averages and standard deviations in

Hospital 16 in Table 2, 3 and 4 is the only

Japan.

private psychiatric institution licensed as a

The deviation value of medical area G andSocial medical corporation (Shakai Iryou-houjin

H is significantly high and low, respectively,

in Japanese), which suggests the hospitalwhich shows the uneven distribution ofundertakes a very high level of public-interest

psychiatric beds in Osaka, Japan. The causal

activity.

medicalfactors for situation remain to be investigated,

corporation was established in 2008 31 . This

though the result here is similar to that offeredsystem aims to act strongly in the publicin the discussion of Table 4. Medical area Ginterest.

medicalreceived excessive total psychiatric beds (Table

corporations in Osaka, Japan is 31 as of 1 April,5), but was not successful in obtaining

201632.

psychiatric emergency beds (Table 4).

The

The

systemofnumber ofsocialsocialHospital 14 in Table 2 and 4 is the only
hospitalestablished

Corporation

bySocial

Welfare(Shakaifukushi-houjin(3) ConclusioninThis study showed that, psychiatric beds asJapanese)33. The other hospitals in Table 2 andwell as incorporated psychiatric hospitals that

4 are established by incorporated medical

have “a license to charge a psychiatricinstitutions.

emergency hospitalization fee,” are distributed
unevenly among medical areas in Osaka.

8. Uneven distribution of psychiatric beds

On the other hand, a hierarchical structure

A working paper No. 352 of the Japan
Medical

Association

Researchof private psychiatric hospitals was observed in

Instituteeach medical area where an incorporated

reported the distribution of psychiatric beds inpsychiatric hospital possessing “a license to

Osaka (www.jmari.med.or.jp). The reported

charge a psychiatric emergency hospitalization

deviation value of the number of psychiatricfee” is located.

beds per person for each medical area is shown

The result of this study might provide ain Table 5,. Letters A–H in Table 5 corresponds

framework for investigating other types of
hospitals in the absence of internal hospital
data.

Table 5. Uneven distribution of psychiatric beds

A limitation of this study is that theinternal controls utilized in each hospital could
not be discerned because of too limitedly
Source: This Table is created based on the data in thedisclosed data, and that the hierarchicalwebsite; www.jmari.med.or.jp.

formation process of incorporated psychiatricIseikyoku/0000073016_10.pdf

31 http://www.mhlw.go.jp/topics/bukyoku/isei/igyou/

33 The Ministry of Health, Labor and Welfare:dl/shakaiiryouhouzin1.pdf
32 http://www.mhlw.go.jp/file/06-Seisakujouhou- 10800000-

http://www.mhlw.go.jp/bunya/seikatsuhogo/shakaifukushi-jigyou3.html

13

Journal of Japanese Management Vol.1, No.1, November 2016

ISSN 2189-9592

hospitals could not be investigated utilizing

Soshikitime-series data.

Institutions). Tokyo: Dobunkan Shuppan.

(Self-reforming

MedicalIn the future, the process formation of the

Matsubara, Yumi, and Tanaka, Shigeru (2004).

psychiatric hospital system remains to be

Iryou-houjin no gavanansu ni tsuite (Oninvestigated from an historical viewpoint in

the governance of incorporated medicalorder to reveal the systems influencing Japan’s

institutions). Tokyo: The ministry of Health,

medical institutions.

Labour and Welfare. (http://www.mhlw.go.
jp/topics/bukyoku/isei/igyou/igyoukeiei/ken

References

toukai/4k)

Fujioka, Eiji (2013). Iryokikan no Gavanansu to

Takaya, Masahiko (2015). Nihon ni okeru

Kansa (The governance and inspect of

Byouin-seido no Sinka to Kouekisei ni

medical institutions). Tokyo: Chuokeizai-

Kansuru

Sha.

Senmon-i Seido wo Reitoshite - (OnKousatsu-

Ipanbyouinto

Hotta, Kazuhiro (2012). Hi-eirisoshiki no Riron

Evolution of Hospital System in Japan andto Konnichitekikadai (The theories about

Public Interest of Japanese Hospitals -nonprofit

current

Especially on Regular Hospitals and on

subjects of research). Tokyo: Maruzen

Training for Specialists -). Journal of

Publishing.

Association for Research on NPOBP, Vol.17,

organizations

andKawabuchi, Koichi (2004). Dairokuji Iryohou

pp.107-120.

kaisei no Pointo to Taiousenryaku (The－ (2016). Iryou-houjin ni okeru gavanansu topoints of the 6th revision of the Medical

akutibiti

Care Act, and the strategies for it). Tokyo:

Jishoubunsekijyoron- (The RelationshipJapan Medical Planning.

between Forms of Governance and Activity

Kazamatsuri, Hajime (2001). Wagakuni noin-Seishinkabyouin

Incorporated

Medicalni

okeru

Institutions-

Seishinka-iryou wo Kangaeru (On thePreliminary

psychiatric medical care in Japan). Tokyo:

Analysis of Psychiatric Hospitals-). Journal

Nippon Hyoronsha.

of Association for Research on NPOBP,

Matsuo, Makoto (2009). Gakushu-suru Byoin

Research

for

Empirical

Vol.18, pp.39-49.

(Received: May 31, 2016)(Accepted: August 29, 2016)14