Effectiveness of Management of Improvement of the Quality of Medical Services in Public Medical Institutions of Israel

The objective of this study was to assess the proposed introduction of out-of-pocket funded inpatient and outpatient services (abbreviated as PMS) into government acute-care hospitals in Israel. This issue of public-private mix in not-for-profit hospitals is discussed in terms of the experience with PMS gained in selected advanced market economies. Then, the major contours of the Israeli system of health care, and the gradual evolving of patient-financed medical services within government acute-care hospitals in Israel, is described. The experience gained in the few public hospitals in Jerusalem that have been operating PMS is assessed critically. The concluding part reviews the advantages and disadvantages of these developments in public and government acute-care hospitals in Israel. It is concluded that PMS in public hospitals in Israel represents a policy aimed primarily at benefiting a select group of senior physicians in those hospitals.

BackgroundHealth systems worldwide function in constantly changing local and global ecosystems. This is the result of economic, demographic, and technological changes, among others. In recent decades Israel has started implementing reforms in the public health services that have led to far-reaching changes in the health system, and consequently, increased competition within it. The impact of these changes has been exacerbated by pressure to reduce per capita public health costs, coupled with increased demand and greater health awareness. All these changes have created a turbulent environment for healthcare organizations in Israel. To cope with this dynamic environment, various parts of the system have had to adopt appropriate management behaviors and business styles. This study, carried out in six public hospitals in Israel, evaluates the nature and degree of adaptation, implementation, and inculcation of management strategies in public hospitals in Israel, using the Ginter model of strategic management of health organizations.MethodsThe study used semi-structured in-depth interviews of key figures in the health system and managers at various levels in the hospitals and HMOs included in the sample. The 55 interviews, conducted in two time periods, were analyzed in accordance with an established theory of qualitative methodological analysis.ResultsThe main findings are that the health market and hospitals in Israel are increasingly adopting competitive business behaviors. But strategic managerial behavior has been adopted only in part, and there is a lack of collaboration between staff and management in defining goals and strategic activity. These are obstacles to change and inculcation of the strategy in hospitals.ConclusionsThis study affords an important view over time and a better understanding of the behavior and adaptation of hospitals in Israel to their constantly changing surroundings. Adapting and inculcating appropriate managerial strategies in hospitals requires close collaboration between staff and management; its absence is an obstacle that contributes to partial, and possibly counter-productive, strategic behavior.The solution may lie in a combination of changes: providing hospital management with the necessary tools and broad professional support by the Ministry of Health; organizational changes in hospital management and departments; the creation of a clinical leadership role; and a self-supervised planning system .Policy recommendationsThese recommendations regarding training and the direction and organization of the change, coupled with systemic oversight of them by the Ministry of Health, will enable the system to become more efficient. They are particularly relevant today because the Covid-19 pandemic has exacerbated and highlighted Israeli public hospitals’ financial and organizational problems. Hospitals that already faced many challenges have had to cope with an unfamiliar medical crisis and a reduction of elective medical activity, causing them various types of damage, especially in term of economic stability.The hospitals’ fragile situation must become a top government priority because it can no longer be ignored. To achieve a strong healthcare system with stable hospitals, able to respond both to everyday challenges and to crises like the current pandemic, policymakers must provide financial and organizational support alongside managerial training, while maintaining an overall systemic plan.

Diversity is growing in work organizations and inclusive climates are gaining increasing significance. The Optimal Distinctiveness Theory (ODT) can be applied as an organizational framework that designates both belongingness and uniqueness as components of inclusion. The study sought to examine the experiences of healthcare workers who are members of a minority ethnic group in the context of a violent conflict. Fifty in-depth interviews were conducted with healthcare professionals – Jews and Arabs – employed at eleven public hospitals in Israel. The interviews reveal the diversity of staff members at Israeli public hospitals. Arab workers, specifically, experience both belongingness and uniqueness. The former is reinforced by values of humanism and professionalism, whereas the latter cannot be fully manifested: Their cultural and religious uniqueness is respected, but their opinions regarding the Israeli-Palestinian conflict are silenced. They experience tension and ambiguity and their inclusion in the organization is not effected in full. ODT implementation will improve our understanding of how to achieve inclusion of minority group workers in healthcare organizations, particularly in conflictual contexts.

BackgroundThe Israeli public health system has seen a steady decline in public trust and confidence, which has resulted in an increased rate of individuals holding private and commercial health insurance policies that allow more choice of various services (especially choose the surgeon’s). This study evaluated the attitudes and beliefs of Israeli adults regarding public trust, equitability and choice within the public health system.MethodsA cross-sectional telephone survey conducted among a representative random sample of Israeli adults (> 25 years). Participants responded to a 27-item questionnaire. Multivariate regression analyses were performed to determine the contribution of various socio-demographic variables to the perceptions of trust and equitability in the health system and the ability to choose a surgeon, As well as a possible links among these parameters.ResultsOf 865 adults that responded to the survey, most were women (51.8%), Jewish (68.6%), and married (73.0%). Trust in the public health system, the perception of the system’s equitability and the public’s perception of the importance of selecting a surgeon were inter-related. The results emphasize a possible association between three meaningful factors: the trust in the public health system, the perception of the system’s equitability and the public’s perception regarding the importance of selecting a surgeon.ConclusionsPublic trust in the public health system is a fundamental condition for maintaining an efficient and equitable health system in Israel. The survey suggests that uncertainty regarding the identity of the surgeon who will perform a procedure in a public hospital may be linked to a sense of insecurity and distrust of the public in the public health system. This study did not examine the causal relationship between the various factors, but the study data suggests a possible link between lower trust in the system and a lower perception of its equitability, and a subsequent associated increase in the public’s desire to select a surgeon. This study suggests to recognize public trust as a central and significant tool to strengthen public health system. One of the ways to strengthen the public’s confidence in the public health system could be to provide the patient with reliable information regarding parameters such as the identity of the senior surgeon in the operating room or the surgeon’s suitability for the patient’s medical condition.

The objective is to assess the impact of workload on pregnancy among women physicians in public hospitals in Israel. A self-administered, cross-sectional study of pregnancies among women physicians in public hospitals was conducted. An 82-item questionnaire was mailed to women physicians in the three largest university hospitals in Israel. The questionnaire assessed demographic data, pregnancy course, perceived stress, and complications during pregnancy. Response rate was 52% (207/400). The complication rates were compared with rates in the Jewish population and expressed as mean SD. Mean number of pregnancies during residency was 1.3 1.2. Mean age at the first delivery was 27 3.2 years. There was a significant difference in the rates of stillbirth (32/1000 births versus 3.7/1000, p < 0.001) and premature delivery (12.4% versus 7.6%, p = 0.0014) between women physicians and the general population. There was no significant difference in the proportion of spontaneous abortions (12.7%), pregnancy induced hypertension (3.2%), hyperemesis gravidarum (3.2%), and diabetes (1%). Seven percent of women physicians changed their specialty due to pregnancy while in residency. Our results suggest that working long hours in a stressful occupation in a hospital environment has an adverse effect on pregnancy course and is associated with increased rates of stillbirth and premature delivery.

Hospital signage is a critical element in the patients’ and visitors understanding of directions, instructions and warnings in the facility. In multilingual environments organizations need to make sure that the information is accessible in the languages of the people who consume their services. As part of a large-scale study that examined the status of cultural competence in public hospitals in Israel (Elroy and Schuster 2016), we examined the signage in ten large hospitals. We developed an “accessibility index”, a mathematical tool that quantifies the level of language accessibility of the hospital signage. According to the data, many geographical areas in the hospitals, as well as certain informational domains, appear in Hebrew only. A lack of clear and unified language policy regarding the nature and scope of multilingual signs in the healthcare system results in loss of critical information for people speaking the minority languages. The further one proceeds into the hospital, the less accessible it becomes. Moreover, certain sign types, such as behavior in emergencies, prohibition and information, are inaccessible for speakers of English, Arabic and Russian. The paper concludes with policy and practical recommendations that will help policy makers to apply linguistically accessible signage, thus enabling patients to orientate in the hospitals and make the best of their stay there.

The National Committee for Hospital Preparedness for Conventional Mass Casualty Incidents and the Hospital Preparedness Division of the Home Front Command are in charge of preparing live exercises held yearly in public hospitals in Israel. Our experience is that live exercises are limited in their ability to test clinical decision making and its influence upon incident management. A live exercise was designed upon real patient data and tested in several public hospitals. The aim of the manuscript is to describe the impact of this new format on clinical decision making in large-scale live exercises. A database of histories, physical examination findings, laboratory results and imaging results for 420 patients treated following terrorist explosions was created using information derived from actual patient encounters. Similar information for 100 patients treated following motor vehicle accidents was also collected. Information from the database was used to create victim profiles used during the course of exercises held in eight public hospitals with 60-800-bed capacities. Before implementing the new injury tags, no conclusions could be made concerning the quality of clinical decision making. Conducting the exercise using the new format helped identify deficiencies in the hospital disaster plan in triage, emergency department management and in the proper utilisation of resources such as radiology, operating rooms and the secondary transfer of patients. Previous knowledge of patient diagnoses and resource needs allow the identification and quantification of deficiencies and problems identified in clinical decision making, resource utilisation and incident management.

The aim of this study was to understand how Israeli hospitals improve several domains related to quality of care in its broadest sense, including clinical quality, patient safety, patient experience, waiting times for outpatient visits and clinicians’ well-being. Questionnaires were send to leaders of public hospitals in Israel. These questionnaires inquired which methods are used to improve quality (e.g., email communication, annual work plans, computerized reports, etc.). Of 29 public hospitals, 14 responded. On the whole, similar methods were used for most topics. These included discussions at the leadership level, formal meetings to discuss issues between leadership and departments, email communications and annual work plans meeting. Domains which were less likely to be under leadership’s focus were waiting times for procedures and outpatient visits, and clinicians’ well-being. Several methods, such as computerized reports, or quarterly follow-up meetings with departments were used less frequently. We can conclude that a global framework for introducing quality in Israeli hospitals is needed.

BackgroundUsing data obtained from the National Satisfaction Survey in General Hospitals, 2014, the present study examines patients’ satisfaction with medical care and hospitalization conditions in the public hospitals in Israel. Using the framework of ‘voice’ expression the study examines the added-value of analyzing verbal responses to gage patient satisfaction. MethodsThe analysis utilizes a series of closed-ended questions to construct indexes of patients’ satisfaction with medical doctors, nursing staff, and hospitalization conditions for a sample of 11,098 patients who were hospitalized in the 25 public hospitals. In addition, a content analysis was applied to the verbal responses (open ended question) to create categories of complaints. Using logistic regression models, we analyzed the social and demographic correlates of high satisfaction, and estimated the relationship between verbal complaints and satisfaction scores. ResultsAnalysis of the satisfaction measures shows very high levels of patient satisfaction coupled with low variance. Yet, detailed analysis of responses to an open-ended question reveals considerably more critical assessments of the hospitalization experience. ConclusionThe findings illustrate the limitations of closed-ended satisfaction items as the sole instrument for assessing the quality of medical care and underscore the value of the use of mixed methods as a more nuanced approach.

BACKGROUND:Today, hospitals need managers who, in addition to having the necessary skills for management and leadership, are accountable to stakeholders, especially the community. Accordingly, the purpose of this study was to evaluate the social accountability of managers of public and private hospitals in Tehran.MATERIALS AND METHODS:The present study is descriptive-analytical and cross-sectional and was performed on 155 managers of selected public and private hospitals in Tehran. The research tools included a demographic characteristic questionnaire and a researcher-made social accountability questionnaire for managers. Data analysis was performed using descriptive and inferential statistics in SPSS 22 software.RESULTS:The situation of social accountability in the managers of public hospitals was at a weak level and in the managers of private hospitals in Tehran was at a good level. In comparing the status of social accountability and its dimensions in the managers of public hospitals with the managers of private hospitals, the status of social accountability in the dimensions of human resource management, quality improvement, executive management, and overall social accountability were significantly different from each other (P ≤ 0.05). However, in terms of governance, the status of social accountability of public hospital managers was not significantly different from private hospitals (P ≥ 0.05). Overall, the results of social accountability in private hospitals were better than in public hospitals.CONCLUSION:The social response status of managers in private hospitals was better than public ones. Lack of attention of managers to social accountability affects the quality of other educational, health, and medical services. This fact raises the need for managers to pay more attention to the issue of social accountability.

Introduction. Heads of medical organizations operating under the Moscow Healthcare Department are the ones who take care of internal control of quality and safety of medical care [1-7]. However, once the healthcare system in Moscow switched to the Unified Medical Information Analysis System (UMIAS), abandoning all the other automated information systems the city had previously used (such as Medialog, Megaklinika, Asklepios etc.), Moscow’s medical workers found it impossible to automatically unload certain statistical (analytical) reports. They have to use paper medical records and logs to register the results of the medical care quality control [1, 2, 6]. Many engineers and programmers working in Moscow’s medical system organizations attempted uploading the medical record data and create automated logs within the UMIAS system; however, they failed [4, 8, 9, 10]. That is why they started creating intranet web portals, integrating them with various internal Moscow healthcare systems (such as UMIAS etc.) as well as well as external Federal Compulsory Medical Insurance Fund systems (like the PUMP system for personalized medical care records). This allowed logging in the results of internal quality control and automatically creating statistical and analytical reports, as well as monitoring the document exchange between various offices of Moscow healthcare organizations [11-14]. To ensure the efficiency of these intranet web portals, medical workers responsible for quality control develop checklists that feature pre-approved criteria for evaluating the results of treatment for certain diseases (conditions) in accordance with medical care provision standards and clinical recommendations. Moreover, the comprehensive introduction of intranet web portals helped ensure that clinical recommendations are followed in Moscow healthcare organizations. In fact, it allowed conducting an automated medical and economic examination, similar to the ones carried out by health insurance organizations within the framework of the compulsory medical insurance system as part of state oversight. Goal. To identify the main issues in organizing internal control of quality and safety of medical care associated with the introduction of intranet web portals in Moscow healthcare system’s organizations. Materials and methods. We identified the main issues in organizing internal control of quality and safety of medical care associated with the introduction of intranet web portals in Moscow healthcare system’s organizations. Moreover, we also examined the requirements for checklist development, as well as the difficulties that arise when compiling analytical reports on following the expert criteria and standards of medical care provision and clinical recommendations. Findings. The list of the main issues associated with the introduction of an automated system for organizing internal control of quality and safety of medical care via multi-user intranet web portals includes: training heads of structural units responsible for organizing and carrying out the internal control of quality and safety of medical care; developing checklists using the pre-approved criteria, rules and requirements for providing medical care in accordance with standards and clinical recommendations; and developing an activity plan for organizing various checks (audits) and compiling analytical (statistical) reports to assess the activities of the Moscow healthcare organizations’ structural units (or employees). The checklists must feature codes of MES (medical and economic standards), ICD-10 (10th revision of the International Statistical Classification of Diseases and Related Health Problems) and medical services, as well expert criteria mentioned in acting legal documents. This is complicated by the fact that the codes of medical services in the UMIAS system differ from the codes featured in the approved medical service nomenclature, whereas expert criteria undergo frequent updates. Conclusion. To ensure the successful implementation of management responses, one needs to regularly host internal meetings with heads of structural units as well as employees responsible for organizing and carrying out internal control of quality and safety of medical care, and timely develop checklists in accordance with pre-approved standards, assessment criteria, rules and requirements of enforcement authorities while taking into account the latest clinical recommendations. To ensure proper control over following medical care provision standards in accordance with clinical recommendations and, therefore, avoid deductions and fines issued by oversight bodies, one needs to adopt a comprehensive approach to internal control of quality and safety of medical care at every level (stage), including heads of department, deputy chief doctors, deputy heads for clinical expert work etc.

The purpose of this paper is to confirm the core competencies required for middle to senior level managers in Victorian public hospitals in both metropolitan and regional/rural areas. This exploratory mixed-methods study used a three-step approach which included position description content analysis, focus group discussions and online competency verification and identification survey. The study validated a number of key tasks required for senior and middle level hospital managers (levels II, III and IV) and identified and confirmed the essential competencies for completing these key tasks effectively. As a result, six core competencies have been confirmed as common to the II, III and IV management levels in both the Melbourne metropolitan and regional/rural areas. Six core competencies are required for middle to senior level managers in public hospitals which provide guidance to the further development of the competency-based educational approach for training the current management workforce and preparing future health service managers. With the detailed descriptions of the six core competencies, healthcare organisations and training institutions will be able to assess the competency gaps and managerial training needs of current health service managers and develop training programs accordingly.

The high costs of health care mandate a quality control system that ensures efficient utilization of hospitalization days. To obtain a national estimate of the rate of inappropriate hospitalization days in medical wards and to identify the variables associated with inappropriateness. A 1-day cross-national survey. A sample of internal medicine wards in all public hospitals in Israel. SURVEY POPULATION: The survey population included all patients hospitalized in the ward for at least 24 hours on the survey day. We used an adapted version of the appropriateness evaluation protocol (AEP) (Gertman and Restuccia). Reviewers were final year medical students trained to work with the AEP. Final classification of inappropriate days was done by one of the senior investigators. Utilization of hospitalization days according to the AEP. A total of 1003 hospitalization days in 33 medical wards in 24 hospitals was surveyed. Of this, 182 (18.1%) of the days were found to be inappropriate. In multiple logistic regression analysis, variables significantly associated with inappropriate days were government versus other hospital ownership (OR, 1.51; CI, 1.15-1.96), diagnosis on admission of acute cardiac event versus other diagnosis (OR, 0.46; CI, 0.27-0.77), and period (first, second or final third) of the stay (OR, 1.61; CI, 1.29-2.03). In 62.6% of the 'inappropriate days', continuation of hospitalization was justified (72% were patients awaiting tests or consultation). In 6.7% of the total days surveyed, no justification for continuation of hospitalization was found. The percentage of inappropriate days found in this study is similar to the means found in studies that were conducted in other countries. Awaiting procedures and consultation is a major cause of inappropriate days and may be an important target for intervention.

Background‘Out of Hours Surgery Service’ (OHSS) was implemented in Israel, amongst other reasons, in order to reduce the time interval between hospital admission and surgery and consequently improve outcomes. The OHSS is currently operated in the public hospitals in Israel. In this study we compared the data of patients before and after OHSS implementation to determine its efficacy in improving patient care.MethodsThis is a retrospective observational study of 792 adult patients who underwent hip fracture surgery between 2002 and 2007 in a single hospital. The study population included two groups: patients that were operated before the implementation of the OHSS (2002–2004) and after the implementation of the OHSS (2005–2007). Data regarding all patients was collected using the institution’s computer program. The following variables were analyzed: patients’ demographics, time interval from hospitalization to surgery, causes for delaying surgery, post-operative length of hospitalization and mortality.ResultsPatients in the post-OHSS group had more illnesses and higher ASA classification than those in the pre-OHSS group. The post-OHSS group had a significantly decreased length of stay in the hospital before and after the surgery. After adjusting for ASA score and age, the post-OHSS group was found to have decreased post-operative hospitalization and lower post-operative mortality. Surgery was delayed in pre-OHSS period mainly due to operating rooms unavailability.ConclusionImplementation of OHSS facilitated operating room availability, thus early operation and reduced post-operative mortality. In accordance with other studies, patient’s outcome is greatly influenced by the time from admission to hip fracture surgery.

Background International studies report a decline in 30-day and 180-day all-cause mortality after non-ST-elevation myocardial infarction (NSTEMI). However, studies on temporal trends of more extended follow-up periods after NSTEMI are lacking; similarly missing are studies on temporal trends of cause-specific mortality after NSTEMI. Purpose To assess temporal trends in the long-term (5-year follow up) all-cause and cause-specific mortality of patients admitted in the years 2000 to 2013 with NSTEMI. Methods We obtained baseline characteristics and admission data from the Acute Coronary Syndrome Israeli Surveys (ACSIS). ACSIS surveys have been conducted since 2000, once every 2 or 3 years, each year for eight consecutive weeks, among all patients admitted with acute myocardial infarction or unstable angina pectoris (ACS) in all public hospitals in Israel. Additionally, we obtained data on all-cause and cause-specific mortality (until 2017) from the Israel Centre for Disease Control. Cox regressions and competing risks models were employed to assess survival temporal trends. Results Among the 4,437 patients admitted with NSTEMI [mean age 65.9 (SD 13.1) years, 75.4% male], 1,127 deaths (25.4%) occurred during the 5-year follow-up. There were no changes over time in the percentage of male patients or the patients’ average age. However, the burden of comorbidities increased over time: the proportion of NSTEMI patients admitted with at least 2 comorbidities increased from 50.8% in 2000 to 64.4% in 2013 (Ptrend&amp;lt;0.001). Compared to NSTEMI patients admitted during 2000-2004, and adjusted for age and sex, NSTEMI patients admitted during 2006-2008 and during 2010-2013 faced 14% and 19% lower risk (respectively) of all-cause mortality (HR=0.86, 95% CI: 0.75-0.98 and HR=0.81, 95% CI: 0.70-0.94, respectively; Ptrend &amp;lt;0.001). However, trends diverged between cardiovascular (CV) and non-CV deaths (see Figure). Whereas, adjusted for age and sex, patients admitted during 2010-2013 had 46% lower risk of CV deaths than patients admitted during 2000-2004 (HR=0.54, 95% CI: 0.42-0.68; Ptrend&amp;lt;0.001), the risk of non-CV deaths remained unchanged (HR=0.99, 95% CI: 0.80-1.22). As a result, the percentage of 5-year CV deaths among all fatalities consistently decreased (51.0% in 2000-2004, 44.4% in 2006-2008, and 39.0% in 2010-2013; Ptrend=0.002). Conclusions Substantial improvement in 5-year mortality was observed among patients admitted in Israel between 2000 and 2013 with NSTEMI. Given that the decline was mainly due to reduction in CV mortality, it is advisable to adopt a more comprehensive approach to NSTEMI patients and address comorbidities.