Creating patient safety capacity in a nation's health system: A comparison between Israel and Canada

In 1966, the National Academy of Sciences published the report "Accidental Death and Disability: The Neglected Disease of Modern Society", [1] demonstrating that soldiers who were seriously wounded on the battlefields of Vietnam had a better survival rate than those individuals who were seriously injured in motor vehicle accidents on California freeways. The response in the U.S. was swift. The Paramedic, a new health care profession, was created; helicopters were introduced to facilitate timely transportation of injured patients to hospitals; and the Emergency Medical Services' response time was reduced. In Baltimore, Dr. R. Adams Cowley founded the Shock Trauma Center, a hospital dedicated to caring for trauma patients; many other trauma centers were established throughout the U.S.

In the last decade of the 20th century, accumulating evidence and sentinel publications focused on adverse events and iatrogenic injury in health care. Anesthesiologists were the first to investigate the huge numbers of mishaps in anesthesia and establish a foundation for improving patient safety. The Australia Health Care Study, [2] "To Err is Human: Building a Safer Health System", [3] and "An Organization with a Memory" [4] revealed that large proportions of hospitalized patients in Australia, the U.S., and the U.K. have suffered an adverse event. A substantial proportion of the adverse events, many of them deemed preventable, resulted in death or severe injury.

Following the publication of these reports, each of the involved countries established high profile committees with a mandate to examine the issue of patient safety and develop recommendations to address system deficiencies. These efforts have included strong support from federal and state governments. In addition, a variety of professional groups, employers, regulators, and healthcare providers have initiated a wide range of efforts to address this issue. Other countries have had a wide range of responses to the need for patient safety. In this paper, we examine two countries, Canada and Israel, and consider some of the essential steps for any country and some possible next steps for Israel. Canadian and Israeli healthcare systems are similar: both are based on public services that are regulated by government. This, in addition to the authors' familiarity with activities in recent years in Canada and Israel, allows for a rich description of the current status in both countries, as well as appropriate recommendations.

The Canadian Adverse Events Study, published in 2004, [5] revealed that, similar to other countries, 7.5% of all patients admitted to acute care hospitals in Canada experienced an adverse event. Over a third of all adverse events were judged to be preventable; 20.8% of patients with adverse events died. Although this was the first large-scale report of Canadian data, activities to address patient safety concerns in Canada started prior to 2004.

A series of symposia was held annually in Canada to raise awareness of the problems among healthcare professionals, provide information and training to people working in the new patient safety disciplines, import lessons and tools from other countries and industries, and advance the field of patient safety generally. These annual events, known as the Halifax symposia, ran for ten years, commencing in 2001 and concluding in 2010 [6].

In September 2001, following a one-day forum on patient safety hosted by The Royal College of Physicians and Surgeons of Canada, the National Steering Committee on Patient Safety was first convened. In September 2002, the Steering Committee published Building a Safer System, a comprehensive document listing 19 key recommendations for work that must be undertaken within the national integrated strategy [7]. The report suggested five major objectives, including (i) establishing a Canadian patient safety institute to facilitate a national integrated strategy for improving patient safety; (ii) improving legal and regulatory processes; (iii) improving measurement and evaluation processes; (iv) establishing educational and professional development programs; and (v) improving information and communication processes.

Less than a decade later, much progress has been made in all areas identified by the Steering Committee in 2002, as follows:

After the 1966 National Academy of Sciences report, in Israel, "Doctors for Trauma", a group of IDF physicians, observed that the Israeli reality was similar. They claimed that trauma-related mortality would decrease by 40% if hospitals opened trauma units and if Magen David Adom (the Israeli national emergency medical services) would join the "trauma system". The Ministry of Transportation, not without resistance, eventually supported the required services. As predicted, trauma-related mortality decreased substantially [30].

The beginning of patient safety activity in Israel is documented in The Patient Safety Handbook[31]. Without any support, a group of physicians and Human Factors engineers carried out one of the first studies on the nature and causes of human error in the intensive care unit [32]. The chapter "How We Started Patient Safety in Israel: Without a Budget but with Enthusiasm" describes how hard it was at the time to publish the study's findings, a rate of 1.7 errors per patient per day. It took years to get partial recognition that we were dealing with an epidemic that is not limited to the North American healthcare system. Hadassah Medical Center joined the Center for Safety at Work and Human Factors Engineering (Technion, Haifa) and together they organized the first conference on medical safety in Israel titled: Avoiding Human Error in the Hospital: Mission Possible?! (see Figure 1). Dr. Richard Cook from the University of Chicago was the keynote speaker and delivered the message that this epidemic is treatable. He took a picture of the 30 participants and told them that this was the nucleus of the future safety movement. Over a decade later, it seems that Dr. Cook was right: all of the participants are active in different domains of the patient safety movement.

Unfortunately, the Israeli government has not taken a leading role in this mission. In spite of continuous demands and requests by a group of researchers from the Technion and Hadassah Medical Center to the Ministry of Health to adopt the American and Canadian approach to improving medical safety, including the submission of a comprehensive plan to reduce medical errors on a national level, a transformative change has not happened yet.

The Israel Ministry of Health has been investigating errors reported by law, as well as patient complaints and occasionally work processes in various healthcare settings. Patient safety alerts have been disseminated to patient safety officers at relevant medical institutions. Working under the confidentiality laws provided by the Patients' Bill of Rights 22.a, patient safety aggregated information, and the results of investigations, alongside and occasionally with the aid of investigators from the Technion, have been transformed into government issued guidelines and directives aimed at increasing patient safety. However, implementation and enforcement of these regulatory guidelines has traditionally been left to hospital directors, as part of the general belief within the ministry that its role should be one of governance and guidance and that active management should be left to individual hospital directors.

Throughout the years, the ministry has issued several required organizational practices (ROP), such as a double check before the administration of blood products, aiming to improve patient safety. Adhering to such ROPs can certainly decrease the rate of adverse events. However, a reliable process has to be designed and human resources have to be considered before a new directive is given. Furthermore, ongoing evaluation of compliance and clinical outcomes has to take place to inform the effectiveness of any intervention. This approach has not been taken. Indeed, similar to the literature in the area, investigations of several critical incidents have revealed that failures were commonly attributed to problems in the system, and only rarely to personal negligence [personal communication, Yoel Donchin, 2011].

The company providing malpractice insurance to Israeli physicians has been requested to provide clinicians with basic knowledge on human factors engineering to reduce error. As this is a private, for-profit company, it is not surprising that the request was rejected.

A call to implement safety programs has come from Clalit Health Services and from Hadassah Hospital, later from Maccabi Healthcare Services and other private healthcare groups. Understanding that a proactive approach, not just looking back at reported incidents, was needed, weak links in the system have been examined. Currently, at Hadassah two full-time physicians are assigned as safety officers. The Israel Medical Association (IMA), although still represented by lawyers, not by safety specialists, eventually accepted the need to look at safety not just from the union perspective but as a problem that must be addressed.

A range of activities to address different aspects of patient safety has been initiated sporadically by various organizations in Israel. The Quality Assurance department of the Ministry of Health has been leading quality audits nationwide, after developing a peer reviewed system that allows institutions to build and compare quality and safety indicators in a national, equal, inexpensive, and non-threatening methodology. In addition, the government has led the quality assessment program in a primary care clinics project [33]. Efforts in monitoring quality of healthcare services have been also made by the Israel Medical Association and by some of the sick funds. The Clalit Health Services have fully accredited six of their general hospitals with the International Joint Commission; the rest of their hospitals are currently in the process and plan to complete accreditation within the next two years. Five government hospitals are now in the process of preparing for accreditation review, and the next phase is to complete the process at all government-owned hospitals. Education and training for healthcare providers has been increasing and courses are currently offered by Clalit Health Services (school for patient safety), the Israeli Forum for Patient Safety (course in patient safety), all medical schools, as well as the Center for Medical Simulation at the Sheba Medical Center.

In fact, given the much lower level of resources available for patient safety in Israel than in Canada, it is noteworthy that so many activities have been undertaken by a wide range of Israeli governmental and non-governmental organizations. At the same time it is clear that with more resources and better coordination more could be accomplished.

There is a need to improve patient safety in the Israeli healthcare system. The incidence of adverse events and their impact on patients in Israel is unknown, simply because research and data are lacking. However, there is no reason to assume that Israeli reality is different from that in other western countries: roughly one in every 15 patients admitted to a hospital suffers an adverse event.

There are important differences between the Israeli and Canadian healthcare systems. For example, medico-legal insurance is provided in Israel by a private company, as opposed to not-for-profit organizations in Canada. In addition, Canadian healthcare is provided almost exclusively by the provincial governments, whereas in Israel several providers exist, including public, semi-private, and private systems. Finally, the research budget is quite limited in Israel compared with Canada. Features of the Israeli healthcare system will need to be considered when designing a system to create patient safety capacity in Israel.

Injuries to patients by the healthcare system are common and their impact on individuals and systems is considerable. Over the last decade, extensive efforts have been made throughout the world to improve patient safety. Whereas the road to improvement is long and achievements are slow to materialize, the extent of activities must be coordinated and organized at the national level. Such a process has not yet begun in Israel. While some basic concepts and expertise already exist in Israel, there is a considerable gap that needs to be filled. We suggest several steps that should be taken immediately to narrow the performance gap and improve safety for patients in Israel. Learning from the experience of other countries and using already existing resources would save time and money.

Roy Ilan, MD, MSc is an Assistant Professor at Queen's University, Canada and is a critical care and internal medicine physician at Kingston General Hospital. He serves as Faculty at the Master's program in Healthcare Quality at Queen's University, and as a Master Facilitator for the Canadian Patient Safety Institute's Patient Safety Education Program.

Yoel Donchin is a retired anesthesiologist and head of the Hadassah University Hospital's patient safety unit. He is a member of the Technion's Center for Safety at Work and Human Factors Engineering, in Haifa, Israel. His book (with Daniel Gopher), entitled "Around the patient bed - Human factors and safety in health care" (Hebrew) was recently published by Carta http://www.carta.co.il/carta/products/01378.html, publishing house, Jerusalem.