An Analysis of Multi-disciplinary & Inter-agency Collaboration
Case Study of a Japanese Community Care Access Center
Miki Saijo
, Tsutomu Suzuki
, Makiko Watanabe
and Shishin Kawamoto
International Sudent Center, Tokyo Institute of Technology, Tokyo, Japan
Faculty of Liberal Arts, Tohoku Gakuin University, Sendai, Japan
Graduate School of Science and Technology, Tokyo University of Science, Chiba, Japan
Institute for the Advancement of Higher Education, Hokkaido University, Sapporo, Japan
Keywords: Community Care Access Center, Multi-disciplinary and Inter-agency Collaboration, Elderly Care, KJ
Abstract: This study examines the process of collaboration between multi-disciplinary agencies at a Community Care
Access Center (CCAC) for elderly care. Using the KJ method, also known as an “affinity diagram”, in two
group meetings (before and after CCAC establishment) with practitioners and administrators from 6
agencies in the city of Kakegawa, Japan, 521 comments by agencies (214 from a meeting in 2010 and 307
from a meeting in 2012) were coded into 36 categories. In comparing the comments from the two meetings,
the portion of negative comments regarding organization management decreased, while comments on the
shared problems of the CCAC, such as difficult cases, user support, effectiveness, and information sharing
increased. A multiple correspondence analysis indicated that the 6 agencies shared a greater awareness of
issues after the establishment of the CCAC, but the problems pointed out by the agency with nurses
providing in-home medical care differed from those of the other agencies. From this, it has become apparent
that group meetings and comments analysis before and after launching a CCAC could illustrate the process
of multi-disciplinary and inter-agency collaboration.
The aging society is a society in which elderly
people account for a large proportion of the
population. This is a trend we are seeing around the
world, but in Japan it is happening more rapidly and
in significantly larger numbers than elsewhere. By
2025, Japan will have 36 million people aged 65 and
older. This means that the elderly will account for
30% of the total population. We need an effective
health care system for this large cohort of aging
population within the demographic onus structure.
In order to cope with this tendency, the Japanese
government changed the system for elderly care
from institutional health care to community care.
This community care provides the elderly with in-
home nursing and medical care through a
community general support center (CGSC) system
launched in 2008 (Ministry of Health, Labour and
Welfare, 2011). However, Japan’s CGSCs do not
provide the kind of coordinated nursing and medical
care that is provided by such agencies as the
Community Care Access Centers (CCACs) of
Ontario, Canada (OACCAC, 2009). A CCAC
requires multi-disciplinary and inter-agency
collaboration among medical, nursing-care, and
welfare practitioners, but for practitioners in
different fields to work together effectively, trust is
necessary, and this relationship of trust needs to be
established at an early stage (Bromiley and
Cummings, 1995); (McKnight et al., 1998). There is
little research, however, that is based on the analysis
of real-world examples of individuals in different
professions and organizations cooperating with each
other (Okamoto, 2001); (Salmon, 2004); (Paletz,
This study elucidates the process of multi-
disciplinary and inter-agency collaboration by
making a case study of Fukushia, a Japanese-style
CCAC health care system in Kakegawa, Shizuoka
prefecture, and analyzing the comments shared in
Saijo M., Suzuki T., Watanabe M. and Kawamoto S..
An Analysis of Multi-disciplinary & Inter-agency Collaboration Process - Case Study of a Japanese Community Care Access Center.
DOI: 10.5220/0004624604700475
In Proceedings of the International Conference on Knowledge Discovery and Information Retrieval and the International Conference on Knowledge
Management and Information Sharing (KMIS-2013), pages 470-475
ISBN: 978-989-8565-75-4
2013 SCITEPRESS (Science and Technology Publications, Lda.)
group meetings of the participants held just before
and after (2010, 2012) the launching of the CCAC.
2.1 Inter-agency Collaboration
In the UK, there has been an awareness since the
1970s of the need for multi-disciplinary and inter-
agency collaboration in child and adolescent mental
health services (DoH, 1997), and many studies have
been made of the topic (Okamoto, 2001); (Salmon,
2004); (Robinson and Cottrell, 2005); (Salmon and
Faris, 2006). These studies focus on how
practitioners from several different agencies
cooperate in the area of public health for youth, but
many of their conclusions can be equally applied to
the topic of general community care for the elderly.
Okamoto, 2001, for example, examines how
individuals with different professions in different
organizations work together to address the issue of
mental health among gangs of young people who are
at high risk of becoming criminals.
The elements of successful multi-disciplinary
and inter-agency collaboration are communication
and cooperation (Okamoto, 2001); (Salmon, 2004);
(Robinson and Cottrell, 2005); (Salmon and Faris,
2006). McKnight et al., 1998, emphasizes the role of
communication in forging initial relationships of
trust among inter-agency and cross-functional team
members, and makes the following propositions: in
initial relationships, highly trusting intentions are
likely to be robust when (1) the parties interact face
to face, frequently and in positive ways, or (2) the
trusted party has a widely known good reputation.
Still, these studies do not examine the methodology
for achieving good communication among
prospective collaborators nor explain how their
mutual reputations are forged.
2.2 Common Frame of Reference
In a multi-disciplinary and inter-agency team, each
member perceives the goals and problems
differently depending on their knowledge and
interests. This is precisely why it is important that all
participants are aware of their respective perceptions,
convictions and motivations (Marmolin and
Sundblad, 1991). Individuals with different fields of
specialty, however, will each interpret what they see
differently even when they are looking at the same
thing. It is necessary, therefore, that they share a
common frame of reference for interpreting and
integrating the information they communicate
among themselves (Marmolin and Sundblad, 1991);
(Hoc and Carlier, 2002). This common frame of
reference (COFOR) is a mental structure that plays a
functional role in cooperation. COFOR is only
accessible to the observer by means of external
entities, such as input and output (communication
between agencies), or external representations in
common media (e.g., a duty roster) (Hoc and Carlier,
2.3 KJ Method
A common frame of reference is an informal mental
structure, albeit with a societal aspect, that
participants need to build together. At the same time,
this kind of informal structure can be difficult to
recognize and is hard to make transparent. One
solution to the problem of achieving COFOR
transparency within the context of a multi-
disciplinary and inter-agency CCAC is the
application of the KJ method in group meetings and
the creation of diagrams and charts showing the
output from those meetings.
Devised by a Japanese anthropologist named
Kawakita Jiro, the KJ method is a generalized brain
storming technique—what he called an “idea-
generating” methodology—to gather qualitative data
(Scupin, 1997). The KJ method has been widely
adopted in business circles, not so much for
generating new ideas, but for its effectiveness in
consensus making (Takeda et al., 1993). The KJ
method is a theory generating methodology like the
grounded theory methodology of Strauss and Corbin,
1990. In group discussions using the KJ method,
individuals write their opinions as short phrases on
slips of sticky notes or labels. There are four
essential steps in the process: 1) label making, 2)
label grouping, 3) chart-making, and 4) written or
verbal explanation (Scupin, 1997). Everyone in the
group participates in the step 1 process of label-
making. After that, trained facilitators carry out steps
2 through 4, intuitively sorting the labels into groups
and creating a diagram linking the groups with lines
(A chart). This diagram, the so-called A chart, will
help to show the connections and open the way for
new interpretations, and this is the distinguishing
feature of the KJ method (Kawakita et al., 2003).
Participants in a CCAC who are trying to achieve
multi-disciplinary collaboration could apply the KJ
method to create a COFOR for solving the issues
that confront them. A comparison of the diagrams
created before and after the launching of the CCAC
will show how their perceptions of the issues have
changed and should help in clarifying the
collaboration process. In the KJ method, a trained
facilitator creates an A chart giving an overview of
the issues, grouping the problems on the basis of
experience and intuition. This, of course, means that
the diagram will be slanted by the facilitator’s
personal perceptions and assumptions. For the
purposes of this study, the labels generated in the
group meetings were sorted according to the
similarity of the issues they addressed. We did not
attempt to examine the effectiveness of the group
meetings in achieving COFOR, but instead used the
labels as output of the group meetings to define the
process of CCAC collaboration.
3.1 Background
Multi-disciplinary and inter-agency collaboration is
essential for community-based care of the elderly.
Take, for example, the case of an old man who is
released from a hospital after suffering a mild stroke.
He is unable to walk and shows dementia-like
symptoms, but everyone in the family works, and
during the day the old man is left at home alone.
Even in a large city like Tokyo, there is no facility
where an individual like this can be immediately
admitted, and in any case the cost is much too high
for the family. If this man is to get in-home care so
that he will not become totally bedridden, he needs
the coordinated support of the following: A hospital
community coordinator who can decide what kind of
support and guidance the man will need after being
discharged; a senior nursing care manager who can
make arrangements for the home renovations that
will be needed for in-home care; the public health
care nurses and visiting nurses assigned to the area
where the old man lives
Japanese local administrations are often
criticized for being overly compartmentalized, but
for effective community-based care of the elderly,
this kind of tendency needs to be overcome. On the
premise that multi-disciplinary and inter-agency
case-level collaboration is best achieved when all
parties concerned are housed in the same building,
the city of Kakegawa launched a new Japanese-style
CCAC called Fukushia in 2011 with plans to build a
total of five such facilities throughout the city by
2015. Each Fukushia is staffed by personnel from
six different agencies including city hall, the local
social welfare council, the community general
support center (CGSC), a visiting nurses’ station, the
Kakegawa senior care manager liaison association,
and the local city hospital, who cooperate in
providing social welfare services.
In 2010, prior to the launching of the new facility,
the authors were asked by Kakegawa city to
interview the staff of all six agencies. All of the staff
interviewed expressed misgivings of the
organizational management of Fukushia, including
their own agency management: they worried about
how they could work effectively with their
counterparts in such different organizations. It was
evident that collaboration would be difficult even
with a new organizational structure and facility. It
was therefore decided to hold group meetings in
which the KJ method would be applied. This paper
examines the results of two group meetings sharing
the same protocol that were held before (2010) and
after (2012) the Fukushia launching.
3.2 Method
Our research question was, What is the process of
multi-disciplinary and inter-agency collaboration
between administration staff and practitioners within
a highly differentiated and complex system of care
for the elderly?” Our approach to finding an answer
was to carry out a quantitative analysis of the KJ
method label output from the two group meetings.
The labels bore comments made by the staff of the
six agencies about each other.
In our analysis, we looked first to see what kinds
of comments increased or decreased in relation to
the awareness of problems. This was done by
comparing the number of comments made at the two
meetings before and after the launching CCAC, and
recording the difference. Our next objective was to
see if there was any change in the affinity of
awareness of problems among the meeting
participants in the two meetings, and this was done
through multiple correspondence analysis of the
comments made at the two meetings.
The two meetings were attended each time by 29
practitioners and administrative staff from the six
agencies comprising Fukushia. The first meeting
participants were: 8 from city hall; 10 from the
CGSC; 3 from the local social welfare council; 3
from the visiting nurses station; 2 from the local
hospital, and 3 care managers. For the second
meeting: 10 from city hall; 8 from the CGSC; 4 from
the local social welfare council; 2 from the visiting
nurses station; 4 from the local hospital, and 1 care
manager. At each meeting, the 29 participants were
divided into 6 groups and given sticky labels on
which to write their comments; blue labels for
comments about their own agency and red labels for
comments about the other agencies. On the red
labels, participants were asked to write their own
agency name and the name of the agency they were
commenting about. The meetings were chaired by
the lead author of this paper. The red and blue labels
where pasted onto a white board so that everyone
could see what kind of comments were being made
and which agencies were making the comments. The
first meeting produced 220 comments and the
second, 314 for a total of 534 comments. After
excluding 13 illegible comments, 521 comments
were then coded into 36 categories according to the
issue or problem they referred to. This task was
carried out individually by three researchers, and
where the results did not correspond, a final decision
was made through discussion among the three.
Finally, the comments were sorted in a cross-
tabulation table for multiple correspondence analysis.
4.1 Changes in Comment Proportions
For a better grasp of the trends, a comparison if the
change in number of comments between the first and
second meetings was made in categories that had 10
or more comments in total from the two meetings.
Figure 1 shows the change in proportion between the
comments from the first and second meetings,
starting with those showing the greatest increase in
the second meeting at the top of the chart. The
comments that showed the greatest increase in the
second meeting were those related to specific shared
issues of the CCAC. These comments were
classified into the categories of “difficult cases”,
“user support”, “regional collaboration”, “in-home
care”, and “patients”. There was also a notable
increase in the number of comments related to work
procedures, in the categories of “effectiveness”,
“information sharing”, and “complicated
There was little change in the number of
comments made at the two meetings in the
categories of “inconsistency”, “lack of doctors”,
“insufficient human resources”, those related to
problems of organization structure and procedures.
Likewise, little change was seen in the number of
comments related to inter-agency and intra-agency
collaboration. To be more precise, there was an
increase in the actual number of comments, but little
change in the proportionate share of these comments
within the designated categories. A decrease was
evident in the number of comments related to the
organization as such. These were comments on
“agency management”, “compartmentalization”,
“developing human resources” and “insufficient
In the second meeting only, participants came up
with a total of 76 positive comments which included
the following: Comments on cooperation, from the
social welfare council to city hall: appreciation for
taking over when council staffs were absent; from
the CGSC to the care managers liaison association:
appreciation for reporting back on follow-up.
These results indicate that while the six agencies
had many critical comments related to the
organization management at the time of the
launching of Fukushia, after the facility was set up
their comments focused more on such factors as the
quality of general community care services and
specific shared issues of concern, rather than on
criticisms of organizational structure or attitudes.
Difficult cases
User support
Information sharing
Complicated procedures
Regional collaboration
In-home care
Staff absence
Requests for services
Lack of doctors
Inter-agency collaboration
Intra-agency collaboration
Insufficient human resources
Integrated care system
Insufficient publicity
Developing human resources
Agency management
1st meeting (N=214)
2nd meeting (N=307)
Figure 1: Proportion of comments from the two group
−4 −3 −2 −1 0 1 2
−4 −3 −2 −1 0 1 2
axis1 19.95 %
axis2 18.5 %
Care manager association1
City hall 1
Social Welfare Council 1
Hospital 1
Home−visit nursing agency 1
Care manager association2
City hall 2
Social Welfare Council 2
Hospital 2
Home−visit nursing agency 2
Insufficient publicity
Taking on too much
Staff changes
Lack of doctors
Work imposition
Care prevention
Requests for services
Difficult cases
In−home care
Narrow views
Information sharing
Insufficient human resources
Developing human resources
Integrated care system
Diffusion of responsibility
Insufficient explanation
Agency management
Inter−agency collaboration
Intra−agency collaboration
Discharge support
Regional differences
Regional collaboration
Staff absence
Burden imbalance
Complicated procedures
User awareness
User support
Figure 2: Multiple correspondence analysis of comments from the two group meetings; Phrases in black indicate agencies.
The numbers 1 and 2 indicate the first or second meeting, and the phrases in red indicate categories.
4.2 Changes in Awareness Affinity
among the Six Agencies
Figure 2 shows the result of multiple correspondence
analysis of the comments from the first and second
group meetings. This analysis shows that by the
second meeting all but the visiting nurses station had
come to share a similar awareness of the problems.
In the first group meeting, the six agencies shared
similar concerns about agency management,
“information sharing” and “intra-agency
communication”, but by the second meeting their
shared concerns had expanded to encompass specific
problems of health care, such as “regional
collaboration”, “lack of doctors” and “discharge
The meeting participants from the visiting nurses
station only raised issues within their own
organization and made absolutely no comments
about the other agencies. The issues they raised
included such topics as—“With only 3 fulltime staff,
there is considerable after-hours burden”, “it is
difficult to establish an effective visiting program
plan”, “there are citizens and care managers who are
unaware of the visiting nursing program” and
“financial difficulties in management”—all issues
that are difficult for the visiting nurses agency to
solve on its own. The fact that the visiting nurses
agency is the only private business participating in
Fukushia is probably a contributing factor to the
problems the visiting nurses appear to have in
communicating with the other agencies, but it should
also be noted that the issues raised by nurses tend to
be introverted. The services provided by the visiting
nurses are crucial to Fukushia and there is a critical
need to address the issue of how the other agencies
may provide better support to the visiting nurses
The analysis of the comments made at the two group
meetings held before and after the launching of
Fukushia show that there was a change from
criticism of organizational management to a shared
focus on specific issues confronting Fukushia as a
CCAC. It is evident that the six agencies had come
closer to a common awareness of the issues before
them. Clearly, the six agencies had overcome their
mutual fear to forge a stronger awareness of their
shared role as a public provider of general
community care services. At the same time, however,
it was evident that the private visiting nurses station
did not share this general awareness.
Only two or three individuals from the visiting
nurses station attended the group meetings and they
can hardly be said to be representative of their
organization. If general community care is to evolve
from a mere concept to a truly multi-disciplinary and
inter-agency undertaking to provide specific
community services, and if it is to include private
enterprise, strategies will be needed to tackle the
issues that have arisen since the launching of
Fukushia, issues which are represented by the
keywords of “regional collaboration”, “lack of
doctors” and “discharge support”. The next step is to
decide what kind of communication among the six
agencies is needed to achieve this.
In this study, we also proposed a method to clarify
the COFOR in problem awareness among the
Fukusia members. It was found that a degree of
objectivity could be achieved by applying multiple
correspondence analysis to the awareness affinity
diagram created by the meeting facilitators based on
their subjective observations in previous studies.
This led us to the conclusion that it may be possible
to objectively externalize the latent potential for a
multi-disciplinary and inter-agency collaboration
COFOR, using the group meetings and the analysis
of the comments. However, we were not able to
analyze the impact of the group meetings or the
affinity diagram on the awareness of the individual
participants in the meetings. We have therefore been
unable to examine the factors that may have
contributed to the change in the Fukushia members’
awareness. Still, there was discussion among all
participants, after the group meetings using the KJ
method labels, on what changes had or had not taken
place in the year since the launching of Fukushia.
We hope later to apply the theoretical COFOR
framework of Hoc, 2001, to this discussion to
analyze its aspects of cooperative activities.
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