Patient Safety in Israel’s Healthcare System

My wife, Dr. Tamara Weiss, recently became the first (and as of this writing, the only) person in Israel to achieve the Certified Professional in Patient Safety (CPPS) designation.  This accomplishment is not astonishing in the least to those who know my wife personally and/or have worked with her professionally.

Tammi’s background in patient safety is rooted in her formative years.  Her father was a dentist who served on the New Jersey State Board of Dentistry; he had stepped down as that body’s president shortly before his passing.  Though he unfortunately did not live long enough to become my father-in-law, I did have many occasions to discuss with him the nature of his duties as a Board member.  Patient safety was always paramount to him; indeed, patient safety is inherently the Board’s primary concern as a unit of the New Jersey Division of Consumer Affairs.

Tammi’s personal focus on patient safety issues, built in no small part upon the examples set by her father, intensified during her medical school and residency years.  One exemplar of her patient safety perspective became very apparent on an occasion where she and I interacted on a professional matter:

I was employed as an Analyst at what was then the US Department of Defense’s Defense Personnel Support Center (DPSC) in Philadelphia.  Among my many duties was to review various proposed procurements.  I had been tasked with a proposed purchase by the Walter Reed Army Hospital of a linear accelerator for treating cancer patients.  Because the price was estimated to be in excess of a half-million dollars (back in 1985, when a dollar was still a dollar), there needed to be, among other things, a written justification for the procurement because it would be under other than full and open competition.  The contracting officer at Walter Reed had justified the sole-source non-competitive procurement on the basis that the hospital already had the same model installed and operating, and if the same patient were to be given multiple treatment sessions on different models by different manufacturers, then redundant time-consuming and labor-intensive preparations would be necessary; identical models would avoid the duplicative preparatory evaluations and facilitate the treatment courses of more patients in far less time.

Tammi at the time was doing her Radiation Oncology residency.  I telephoned her at work and said, “This phone call is official government business.”  I then explained the situation to her.  She not only confirmed the validity of the contracting officer’s justification, but also noted most assertively that two of the same linear accelerator models would provide less chance for error and inappropriate radiation exposure for patient and hospital personnel alike than would two different models.  Of course, I wrote up a memorandum to document the conversation; my efforts elicited favorable comments from the Headquarters team that reviewed our office files shortly thereafter.

Tammi’s interest in patient safety further expanded during the quarter-century she worked as a hospital staff physician (and interim department chair) in the United States.

***

Olim always have challenges in dealing with the cultural differences between what they had become accustomed to in their birth countries and their new situation in Israel.  Perhaps the most common element of the cultural disconnect is the healthcare system.  Tammi can compare and contrast the United States healthcare system with the Israeli system from the perspectives of both physician and patient; I shall not now even attempt to tell the personal experiences and war stories she herself is best postured to relate.  Tammi has significant reasons to critique respective patient safety issues in America and Israel, and I leave that task for her to do in the appropriate forum.

This posting cannot even begin to give an overview on patient safety, nor will I arrogate my wife’s certified and demonstrated expertise on the matter; suffice it to say that patient safety issues permeate the entire healthcare system and beyond.

I will, however, comment from the perspective of my own professional and academic background, expertise, and experience in law and in organizational management, the dynamics of which are quite relevant to patient safety.

Healthcare has grown increasingly complex and specialized on account of developments in technology, new therapies, and new medications.  Healthcare is delivered less and less by individuals and increasingly by organizations.  And sometimes, the information known at the lower levels of any organization does not reach the upper leadership levels of the organization, or, if it does, is not viewed with appropriate seriousness by the leadership.

Such was the case at Hadassah – Ein Kerem, where concerns on the part of an anesthesiologist that a carbon dioxide tank in an operating room might be mistaken for oxygen were cavalierly ignored by hospital management, and the CO₂ tank remained in the operating room for months after the very type of mishap the anesthesiologist feared did in fact tragically occur.

[Hadassah – Ein Kerem was not the first hospital to have patient safety issues related to administration of the wrong gas to patients.  In 1977, Suburban General Hospital, outside of Philadelphia, had a run of patient fatalities from the mislabeling of its built-in gas lines, whereby patients were administered nitrous oxide instead of oxygen.  This incident led to a medical device standard specification of different hose connector sizes and shapes for different gases – a standard that was relevant in another case I had at DPSC, in which I worked with a manufacturer who sought approval of its medical device for procurement by the U.S. military.  Once the new device was approved and competed with an established sole-source item, the formerly sole-source manufacturer’s people sharpened their pencils and found ways to significantly reduce the price they had previously charged for their item.].

***

There are various cultural aspects of Israeli society that detract from patient safety.  Not the least of these is the “hakol yehiye b’seder” attitude (“All will be fine”).  To be sure, this quintessentially Israeli mindset has long helped Israelis to endure the multiple existential challenges that daily come our way, but it has also instilled a degree of nonchalance amongst the healthcare professionals who treat patients, causing them to give sparse heed to what should be significant procedures, rules, and warning signs.

The Israeli socialization habits and conventions can also pose obstacles to patient safety.  The most obvious of these has been the obstinate resistance to and noncompliance with the social distancing regulations imposed (and re-imposed) upon the country in the wake of the COVID-19 pandemic.  These can be quite deleterious to patient safety when operating in the context of recreational events for hospital personnel, as was recently demonstrated by an apparent CoronaVirus infection propagation at a staff party at the Sourasky Medical Center.

Societies everywhere have long held their physicians in high esteem, but in Israel, this has developed into a societal taboo against questioning a physician.  To be sure, such iatrolatry is also present in the United States, but to a somewhat lesser extent.   Oftentimes, a nurse, physicist, or even another physician of junior status will feel inhibited in bringing a patient safety matter to the responsible physician’s attention.  The problem is exacerbated when the responsible senior physician allows the benefits of his or her attributed infallibility to inflate his or her sense of self-importance.

[I myself have long viewed the medical profession with a palpable degree of cynicism (never mind that my mother’s brother was a physician); the fact that I remain in a stable 30+ year marriage to a doctor is a happy puzzlement.].

But healthcare sector personnel cannot be held totally to blame.  Israel’s policy of encouraging immigration from diverse locales of diverse languages has created language barriers.  Patients who cannot understand the hospital signage, or who have difficulty communicating verbally with the healthcare personnel who are attempting to provide treatment, cannot fully cooperate in their treatment courses and are accordingly more susceptible to unsafe perils.

***

From a management perspective, successful corporate CEOs needs whether personally or by designated proxy, to contemplate future scenarios and prepare their organizations to deal with them.  One memorable story from my business school curriculum was of an insurance executive whose morning newspaper readings included Daily Variety, a publication that covered the entertainment industry.  This executive realized that the expansion of the television industry during the 1950’s would adversely affect the motion picture theatres (which would inevitably lead to increased fire insurance fraud); he therefore directed his organization to accord increased scrutiny to the insurance policies written for movie theatre establishments (and to any claims made thereunder), resulting in better performance of his insurance line compared to many of his competitors.

For various reasons, American society is more litigious than is Israel’s.  Medical malpractice litigation, while certainly not unknown in Israel, is not as robust as it is in the United States.  But worldwide current events being what they are, increased Aliyah to Israel from the United States and other Western countries can be expected in the coming years.

[While I myself never had a med mal case in my USA law practice, I did have cases in which patient’s rights were implicated; increases in patient rights-connected legal disputes can also be expected to follow increased Aliyah from America.].

The executives of the healthcare industry and the insurance industry would now do well to anticipate increases in medical malpractice litigation.  A primary strategy to deal with such a change in the business environment would be to prevent, to the greatest extent practicable, medical mishaps from occurring in the first place.  This would necessarily entail a heightened focus on patient safety issues.

As this piece is being written, a labor strike by Israel’s nurses appears to be in store for tomorrow morning.  Patient safety is being touted as an issue by the nurses’ union and, to an extent, by the union representing the country’s social workers who have been on strike for the past two weeks.

While the assertion of the patient safety issue is no doubt an opportunistic ploy that neatly fits in with the nurses’ (and social workers’) personal interests, the fact that patient safety now is the subject of national discussion is and should be a most welcome development.