National Merit

To Americans used to wrestling with healthcare issues within the context of 50 state governments, the Israeli system starts with a key difference: It's national. That simplifies relations between its local arms (EMS, hospitals) and its national head (the Ministry of Health), as well as its operations with other players (e.g., law enforcement, the military) and during emergencies.

   The country has 27 general hospitals, supplemented by 15 geriatric and 18 psychiatric hospitals and numerous private hospitals, to serve a population of nearly 8 million. There are six Level 1 trauma centers. Healthcare services are provided across 17 districts, while a single national ambulance provider, Magen David Adom (MDA), functions within 11 districts of its own. Four Health Maintenance Organizations (HMOs) provide universal insurance coverage to residents, with core services defined by the government. Physically, it's a pretty healthy population; waits for primary care are short and costs are covered, with copays for specialists only. Citizens average more than seven doctor visits a year.

   The Israeli per-capita acute-care bed rate, 2.2 per 1,000 people, is lower than many western countries', leading to high occupancy rates and low average lengths of stay. An American might expect that to make handling patient surges difficult, but Israeli hospitals are required to be able to increase their routine bed capacities by 20% in surge situations. That doesn't mean backup beds sit empty; just that facilities have to have extra gurneys and gear on hand, plus plans and personnel practiced and ready. Extra capacity can also come via overflow agreements with specialty hospitals. Medical institutions are required to fund their own training and drills (which requirements are substantial), but the government covers equipment, infrastructure and development of doctrine and training materials.
For EMS' part, mutual aid is automatic, with reinforcements drawn from neighboring districts and volunteers ready to roll from home. Private ambulances can also assist in emergencies.

Preparedness

   Emergency preparedness in Israeli healthcare is built on what's called the 5C Model:

   Comprehensive contingency planning: Planning is based on an all-hazards approach focused on common components and the idea that standardization helps build capacity. Equipment and infrastructure are standardized to the extent possible. The common thread in emergencies is knowing exactly what your role is, when, where and with whom.

   Command of operations: Police are always in command of incident scenes. EMS is subordinate but in charge of medical operations, casualty evacuation and communication with hospitals. Fire and environmental-protection providers are also first responders. The military's Home Front Command conducts rescues and directs secondary patient relocation. The Ministry of Health offers logistical support and has overall responsiblity for medical operations.

   Central control: Emergency preparedness and response are coordinated by the Ministry of Health's Division for Emergency and Disaster Management, with policy set by the Supreme Health Authority, which includes representatives from government, hospitals, MDA, the HMOs and others. SOPs are developed, reviewed and approved nationally; then hospitals use them to develop their own standing orders. The national government also monitors hospital capacity and produces after-action reviews of events, as well as conducts annual preparedness evaluations.

   Coordination and cooperation: Healthcare system players utilize a joint communication system and common database to facilitate sharing information. They train and drill together and appoint liaison officers for mass-casualty events. Plenty of practice keeps roles clear and joint operations running smoothly.

   Capacity building: The frequency of training marks one major difference between the Israeli and American systems. It's a regular requirement for hospitals, EMS and volunteers. Each year, Israeli providers undergo simulation exercises and full-scale drills covering all the potential threats they face: conventional and "mega" MCIs, radiological and toxicological events, chemical attacks, biological outbreaks and natural disasters. The belief is that preparedness correlates: Being ready for a mass-trauma event helps prepare you for a mass-toxicological event, which helps prepare you for a biological event, and so on.

The U.S. Perspective

   Much of this will sound familiar to American providers. Some will sound alien. The degree of integration and streamlining in the Israeli system is something we aspire to, but factors characteristic of our system--its variety of service providers and models; America's loose-knit federalist approach to healthcare--inherently impede. We've come a long way with standardization and coordination and learning each other's languages in recent years, but there are still a lot of people doing different things different ways.

   "We have 1,061 EMS organizations in Pennsylvania alone," says that commonwealth's EMS director, Joe Schmider. "Could we do a lot more with just one organization to deal with all the time? There's no doubt about it. If they determine in Israel, ‘We have to do x instead of z,' there's one boss, one employer, and it drives things down very quickly. It would be a whole lot easier, but how do I do that with 1,000 ambulance companies?"

   "One thing I hope we can learn from, even though we're a bigger country and have some different features, is the way they're able to integrate responses among all the different agencies," says Montana EMS boss Jim DeTienne. "Their EMS, fire, police, hospitals, the military, they're all sort of one system, with everybody knowing what the end is and what they want to do today with this incident. They've done a lot toward having the same sort of sheet of paper about who does what, their national doctrine, and executing it in chaotic situations."

   "The government agencies all seemed to have an excellent working relationship between them. It felt like the goals were uniform and everyone was headed in the same direction," says Gary Wingrove, past president of NCEMSI and the National EMS Management Association. "It's a much smaller place than the U.S., but it was interesting to see that everyone had plans that were well integrated and didn't seem to have much duplication."

   The Israelis describe their healthcare system as being on "constant alert." That, America has found, is easier said than done. We've improved our planning and preparation greatly in recent years, but the reality is, a good surge today would throw many systems into chaos. Many of us still struggle to answer ordinary events, never mind extraordinary ones.

   "For a lot of us, surge plan is an oxymoron," says Stein-Spencer. "We don't truly have a surge capacity in our healthcare system, and it's something we need to improve. It's something we can't define narrowly, as just hospitals--we have to look at the healthcare system as a whole. We've started looking at utilizing things like long-term care facilities [in surges], but we're not there yet."

   "We basically don't even have a lot of guidelines for resourcing scarce things," says Heilicser. "Say something big happens, and we need 50 ventilators right now. Who has 50 ventilators ready to run? If you have fewer, who gets them? Whom do you take off ventilators to accommodate those who can better use them? Those are things we think about and talk about, but we don't always have down in policy so that it's transparent for our communities."

   If that's you, now is the time to start working such matters out. Doing it on the fly during a crisis will add to the chaos. And crisis can happen any time.