かしま病院創生マニュアル Ver.0.1
― 面倒見の良い病院は、どうすれば生まれるのか ―
発案者：古田京先生（見学者）
執筆担当：石井敦（宿題を押しつけられた院長）
はじめに ― このマニュアルには重大な欠陥があります
本マニュアルの最大の欠陥は、著者自身が「なぜ、かしま病院がこうなったのか」を十分に説明できないことです。
計画的に現在の病院をつくったわけではありません。
目の前の患者さんを診て、地域の困りごとを見つけ、できることを考えて、試して、失敗して、また考える。
そんなことを20年以上繰り返していたら、いつの間にか現在の姿になっていました。
したがって、これは成功の方程式ではありません。
かしま病院で実際に起きたことを振り返り、再現できる原理を探すための、未完成のマニュアルです。
第1章 必要なものがなければ、自分たちで創る
― かしま病院の創設に刻まれたDNA ―
かしま病院には、「できない理由を探すより、できる方法を考える」という文化があります。
では、その文化はいつ、どのように生まれたのでしょうか。
実は、答えは病院が創られたときにありました。
かしま病院は、地域の開業医仲間が理事となり、地域に必要でありながら、それまで存在しなかった医療機能を実現するために創設された病院です。
「この地域には、こういう病院が必要だ」
そう考えた医師たちは、誰かがつくってくれるのを待ちませんでした。
自分たちでつくることを選んだのです。
これは、単に一つの病院を開設したという話ではありません。
地域の課題に気づいた人たちが、既存の仕組みに限界があるからと諦めるのではなく、必要な仕組みそのものを創り出したということです。
つまり、かしま病院の原点には、すでに現在の組織文化につながる発想がありました。
「ないからできない」ではなく、「必要だから創る」。
その後、病院は地域の変化に応じて、医療と介護の連携、リハビリテーション、救急医療、総合診療教育、そして「いとちプロジェクト」へと活動を広げてきました。
これらは創設時から計画されていたわけではありません。
しかし、地域に必要なものを自分たちで考え、実現するという姿勢は、創設時から今日まで一貫しているように思います。
かしま病院の文化は、後から掲げたスローガンによって生まれたのではありません。
病院の誕生そのものが、その文化の最初の実践だったのです。
原則1：地域に必要なものがなければ、誰かがつくるのを待たず、自分たちで実現する方法を考える。
第2章 「できない」を出発点にする
医師が足りない。専門医がいない。人手が足りない。
普通なら、そこで諦めてしまうかもしれません。
しかし、かしま病院では、そこから考え始めます。
医師一人でできなければ、ほかの医師と分担する。
医師でなくてもできることは、ほかの専門職に協力してもらう。
病院だけで解決できなければ、地域の人たちと一緒に考える。
実際、訪問診療では複数の医師や多職種が役割を分担し、救急医療では職種を越えた検討を重ねて受け入れ体制を改善してきました。
原則2：「できない理由」を確認したら、次に「どうすればできるか」を考える。
第3章 人を育てる前に、人が育つ土壌をつくる
かしま病院には、医学生、初期研修医、専攻医など、さまざまな学習者がやって来ます。
しかし、教育の中心にあるのは、単なる医学知識や手技の習得ではありません。
患者さんの暮らしを知ること。
医療だけでは解決できない問題に気づくこと。
ほかの職種や地域の人たちと協働すること。
そして、自分自身も地域の一員として考えること。
指導医だけでなく、病院職員や地域の人たちも教育に関わる。
これは、長年の地域医療の実践が教育の土壌になった結果とも考えられます。
原則3：教育プログラムを整えるだけでなく、学ぶ価値のある現場そのものを育てる。
第4章 職員を大切にすることを、経営の中心に置く
2011年の東日本大震災は、かしま病院の組織文化を考えるうえで欠かせない出来事です。
原発事故による避難が広がるなか、病院は職員と家族の安全を優先する姿勢を示しました。
それでも地域医療を守ろうとする職員たちがいた。
この経験は、「組織は人を大切にする」という共通認識を強めた可能性があります。
その後も、子育て支援やワーク・ライフ・バランスの改善など、働き続けられる環境づくりを進めてきました。
職員が安心して働けなければ、患者さんを安心して支えることも難しくなります。
原則4：職員の献身に依存せず、職員が安心して力を発揮できる組織をつくる。
第5章 挑戦する人を見つけ、背中を押す
新しいことを始めたいという人が現れたとき、組織には二つの選択肢があります。
前例がないことを理由に止めるか。
実現する方法を一緒に考えるか。
かしま病院では、後者の積み重ねが多様な取り組みにつながってきたように思います。
ただし、何でも無条件に認めればよいわけではありません。
患者さんの安全、地域の必要性、職員の負担、継続可能性を考えながら、実現できる形を探ることが大切です。
原則5：挑戦を許可するだけでなく、挑戦が続くように支える。
第6章 病院の外に出る
2022年に始まった「いとちプロジェクト」は、病院と地域の関係をさらに広げる取り組みです。
医療者が病院の外へ出て、地域の人たちと対話する。
地域の人たちが病院へ来て、医療者や学生と交流する。
医療を提供する側と受ける側という一方向の関係から、ともに地域の暮らしを考える関係へ。
ここでは、医療者が教えるだけでなく、地域の人たちから学ぶことも重要です。
原則6：地域を支援の対象としてだけでなく、ともに医療を育てる仲間として捉える。
第7章 成功事例ではなく、成功を生む仕組みを探す
救急応需プロジェクト、総合診療教育、いとちプロジェクト、職場環境の改善。
これらは一見すると、別々の取り組みです。
しかし、その背景には共通する考え方があるのではないでしょうか。
「地域に必要なことを考える」
「職種の境界を越えて協力する」
「できる方法を探す」
「実践しながら改善する」
そして何より、
「困っている人を放っておかない」
という姿勢です。
これが、かしま病院の「面倒見の良さ」の正体なのかもしれません。
ただし、この仮説が正しいかどうかは、まだ検証が必要です。
最終章 ほかの地域に移植できるものは何か
かしま病院の建物や病床数、診療科構成を模倣しても、同じ病院が生まれるとは限りません。
地域ごとに、必要な医療も利用できる資源も異なります。
むしろ共有できるのは、困りごとを発見し、仲間を集め、試行錯誤を続けるための考え方ではないでしょうか。
つまり、全国に広げたいのは「かしま病院のコピー」ではありません。
それぞれの地域に、その地域に必要な医療を自分たちで育てられる病院が生まれること。
これこそが、古田先生の宿題に対する、現時点での私なりの答えです。
あとがき ― 古田先生へ
病院見学に来た若手医師から、院長が宿題を出されるという前代未聞の事態になりました。
しかも、考えれば考えるほど難しくなる宿題です。
とりあえず、Ver.0.1を提出します。
ただし、まだ仮説だらけです。
古田先生、採点する前に、ぜひ一緒に続きを考えてください。
そもそも、この宿題を出した責任は、先生にもありますからね（笑）。
The Kashima Hospital Creation Manual — Ver. 0.1
How Can We Build a Hospital That Truly Cares for Its Community?
Conceived by: Dr. Kyo Furuta (Visiting Physician)
Written by: Dr. Atsushi Ishii (Hospital Director, Unexpectedly Assigned the Homework)
Introduction — This Manual Has One Major Flaw
The biggest flaw in this manual is that its author cannot fully explain how Kashima Hospital became what it is today.
We never had a detailed master plan for creating the hospital we now have.
We cared for patients in front of us, identified problems in the community, thought about what we could do, tried something, failed, and tried again.
After repeating this process for more than twenty years, we somehow arrived at where we are today.
So this is not a guaranteed formula for success.
It is an unfinished manual—an attempt to look back at what actually happened at Kashima Hospital and identify principles that might be applied elsewhere.
Chapter 1 — If Your Community Needs Something That Doesn't Exist, Create It
The Founding DNA of Kashima Hospital
At Kashima Hospital, we have a deeply rooted habit of looking for ways to make things possible rather than reasons why they cannot be done.
But where did this culture come from?
The answer may lie in the very founding of the hospital.
Kashima Hospital was established by a group of local physicians in private practice who became members of its governing board.
They recognized that their community needed healthcare services that were not adequately available at the time.
Rather than waiting for the government or another organization to provide those services, they decided to create a hospital themselves.
Their starting point was simple:
"Our community needs this. So how can we make it happen?"
This was more than the establishment of a healthcare institution.
It was an act of collective problem-solving by physicians who understood the needs of their own community.
They did not accept the limitations of the existing healthcare system as the final answer.
Instead, they created a new structure to address those limitations.
In other words, the culture we see at Kashima Hospital today did not emerge only after the hospital was established.
The founding of the hospital was itself the first expression of that culture.
Over the years, the hospital has expanded its activities in response to changing community needs, including rehabilitation, emergency care, home-based medicine, general practice education, and the Itochi Project.
These developments were not all anticipated at the beginning.
But the underlying philosophy has remained remarkably consistent:
When something is needed, find a way to make it possible.
Principle 1
If your community needs something that does not exist, do not simply wait for someone else to provide it. Find a way to create it together.
Chapter 2 — Start with What You Cannot Do
Not enough physicians.
No specialist available.
Insufficient staff.
Limited equipment.
In many organizations, these obstacles can bring a discussion to an end.
At Kashima Hospital, we try to make them the starting point.
If one physician cannot manage everything, perhaps several physicians can share the responsibility.
If a task does not require a physician, perhaps another healthcare professional can take the lead.
If the hospital cannot solve a problem alone, perhaps people in the community can help.
Our home-based medical care, multidisciplinary collaboration, and efforts to improve emergency patient acceptance have all involved finding ways to work beyond traditional professional boundaries.
Of course, this does not mean ignoring limitations or compromising patient safety.
It means refusing to assume that the first obstacle must be the final answer.
Principle 2
Once you understand why something is difficult, ask what would make it possible.
Chapter 3 — Before Training People, Create an Environment Where People Can Grow
Medical students, junior residents, and general practice trainees come to Kashima Hospital to learn.
But medical knowledge and technical skills are only part of what we hope they will gain.
We want them to understand patients' lives beyond their diagnoses.
We want them to recognize problems that medicine alone cannot solve.
We want them to learn how to collaborate with other professionals and community members.
And we want them to begin thinking of themselves not simply as physicians working in a community, but as members of that community.
Education at Kashima Hospital is therefore not provided by supervising physicians alone.
Hospital staff, patients, and people from the community all contribute to the learning process.
Perhaps our educational environment developed naturally from years of practicing community-oriented healthcare.
Principle 3
Do not focus only on building a training program. Build a workplace and community worth learning from.
Chapter 4 — Put Staff Well-Being at the Heart of Management
The Great East Japan Earthquake of 2011 was a defining experience for Kashima Hospital.
As the nuclear disaster led to widespread evacuation and uncertainty, the hospital's leadership prioritized the safety of staff members and their families.
At the same time, healthcare professionals continued to consider how they could protect medical services for the community.
This experience may have strengthened a shared understanding that an organization must care for the people who work within it.
Over the years, Kashima Hospital has continued to develop workplace practices that support family life, childcare, and work-life balance.
A hospital cannot sustainably care for its community if its staff are constantly expected to sacrifice their own lives and well-being.
Principle 4
Do not build an organization that depends on endless personal sacrifice. Create one where people can work safely, sustainably, and with pride.
Chapter 5 — Find People Who Want to Try Something New, and Support Them
When someone proposes a new idea, an organization has a choice.
It can reject the idea because there is no precedent.
Or it can ask how the idea might be made possible.
At Kashima Hospital, many initiatives appear to have grown from the second approach.
Consider the physician who wanted to provide orthopedic surgical care for patients in the region.
We did not have a full-time orthopedic surgeon.
That could have ended the discussion.
Instead, people began exploring whether there might be another way.
The physician himself was eager to engage with local residents, including through health talks at community centers.
The starting point was not a perfectly prepared business plan.
It was a genuine desire to meet a community need.
Of course, not every idea should be approved without careful consideration.
Patient safety, staff workload, available resources, and long-term sustainability all matter.
But an organization can evaluate those concerns while still encouraging people to pursue meaningful ideas.
Principle 5
Do more than give people permission to try. Help them create the conditions in which their ideas can succeed.
Chapter 6 — Step Outside the Hospital
The Itochi Project, launched in 2022, has helped expand the relationship between Kashima Hospital and the surrounding community.
Healthcare professionals step outside the hospital to meet residents and engage in dialogue.
Community members come into the hospital to interact with healthcare workers and learners.
The relationship becomes something more than healthcare providers delivering services to patients.
It becomes a partnership in which people work together to think about health, daily life, and the future of their community.
Healthcare professionals are not always the teachers.
Sometimes, they are the ones who have the most to learn.
This is an essential part of our philosophy of caring for the whole community.
Principle 6
Do not see the community only as a population to be served. See it as a partner in creating better healthcare.
Chapter 7 — Look Beyond Successful Projects to the Culture That Produces Them
Emergency care improvement.
General practice education.
The Itochi Project.
Workplace reforms.
At first glance, these may seem like unrelated initiatives.
But perhaps they share a common foundation.
Identify what the community needs.
Work across professional and organizational boundaries.
Find people who can contribute.
Try something.
Learn from the outcome.
And keep improving.
Above all, there may be one attitude that connects them:
Do not turn away from people who need help.
Perhaps this is the essence of what others have described as Kashima Hospital's culture of being a hospital that truly cares.
In the May 2026 issue of the Japanese journal Byoin (Hospital), an article by Shigeto Horinouchi examined Kashima Hospital under the theme of a community-oriented hospital known for its attentive, supportive approach to patients, staff, and medical education.
That outside perspective provides an important clue.
However, the hypothesis still needs to be tested.
We need to understand not only what our culture looks like today, but also how it developed and how it has been sustained.
Principle 7
Do not simply copy successful projects. Investigate the organizational culture that made those projects possible.
Final Chapter — What Can Actually Be Reproduced Elsewhere?
Copying Kashima Hospital's buildings, number of beds, or clinical departments will not necessarily produce the same results.
Every community is different.
Its population, geography, medical resources, history, and social relationships all shape what healthcare should look like.
What may be transferable is something less visible:
The ability to recognize unmet needs.
The willingness to bring people together.
The habit of asking how something can be achieved.
The courage to experiment.
And the determination to keep learning.
In other words, our goal should not be to create identical copies of Kashima Hospital throughout Japan.
Our goal should be to help communities develop healthcare organizations capable of creating the services their own residents need.
That, at least for now, is my answer to Dr. Furuta's assignment.
Afterword — Dear Dr. Furuta
It is probably unprecedented for a young physician to visit a hospital and leave the hospital director with homework.
But that is exactly what happened.
And the homework turned out to be considerably more difficult than expected.
The more I think about it, the more complicated it becomes.
Nevertheless, here it is.
The Kashima Hospital Creation Manual, Version 0.1.
It is still full of unanswered questions.
We have only begun to explore how our organizational culture emerged, which factors were essential, and which lessons might be useful elsewhere.
But perhaps that is precisely why this project is worth pursuing.
Dr. Furuta, before you grade my assignment, I hope you will help me work on the next version.
After all, you are partly responsible for getting me into this situation!
And one more thing.
If this manual eventually helps create community-oriented hospitals in other parts of Japan, it will have been well worth the trouble.
We do not need another Kashima Hospital.
We need more hospitals that are willing and able to become whatever their communities truly need.
That is the future I hope we can help build.
Reference: Shigeto Horinouchi. “A Community-Oriented Hospital That Truly Cares: The Appeal and Education of Kashima Hospital.” Byoin (Hospital), Vol. 85, No. 5, May 2026. (Japanese-language article; English title translated for reference.)
