January 5, 2017
Author: Ronny Linder-Ganz
Source: The Marker
After being built against nearly all odds, the Assuta Ashdod hospital will soon be opening its doors. Shuki Shemer, Chairman of the Assuta Board, guarantees that not only will the building be state-of-the-art, but so will the entire approach to patient treatment. Now all that remains to be seen is how he will accomplish this in an overly-cautious healthcare system, short on doctors and nurses.
The first patient to walk through the door of the Assuta Ashdod ER in six months’ time doesn’t know it yet, but he has already been deemed “the most expensive patient in the history of Assuta.” “An entire hospital will be at his service, with 1,200 employees – 500 nurses, 250 doctors, and 450 administrative and logistical staff members – ready to treat him,” explains Professor Joshua “Shuki” Shemer, Chairman of the Assuta Board and the driving force behind the new hospital. “Therefore, theoretically speaking, he will be the most expensive. With time, these expenses will be dispersed among many more patients.”
“Building a new hospital is an expensive undertaking. Each bed costs NIS 3 million on average, and on top of that, the hospital will cost the government and the healthcare services another NIS 500 million per year for the services it provides. But that’s fine, because filling the shortage of hospital beds is inarguably long overdue.”
Assuta Ashdod’s very first patient won’t only be the most expensive. He will also be standing there against seemingly insurmountable odds. Since the Knesset passed the edict to build a hospital in the city in 2002, a move spearheaded by Sofa Landver, MK, there have been countless attempts to torpedo its establishment – from the Ministry of Finance rejecting it on the basis of the Arrangements Law year after year, to the organized opposition of hospital directors, who warned that its construction was unnecessary and would be disastrous for them.
Only after a prolonged, vocal public battle by Ashdod’s residents, and after the High Court of Justice ordered the law’s enforcement, did the State finally have to reluctantly accept the decision and issue the tender for the hospital’s construction. The tender almost failed as well, and the State, which did not want to build a new hospital itself, piled grant after grant on Assuta, totaling almost NIS 900 million, provided it agreed to take care of construction on its own.
The residents of Ashdod have been campaigning for a hospital in their city for decades, so the hospital will have no problem finding patients. Attracting doctors and nurses to an unknown hospital, however – that’s an entirely different challenge.
Sharap (private medical care) was supposed to be what attracted doctors to the hospital. Once that was cancelled, how did you persuade doctors to leave their secure jobs in more established hospitals and take a leap into the unknown, at a new hospital away from the central region?
Shemer: “This may come as a surprise to you, but we were not the ones trying to attract the doctors – they came to us. It’s true that many doctors pulled out when we gave up on Sharap. But the upside is that the doctors who came on board did so because of the hospital’s unique vision, path and model. People were recruited because they saw a place where their professional aspirations could be realized. Not all doctors are focused on material gain. Many of them just want to practice medicine well. If you give them the appropriate practical and technological means, and the chance to practice medicine in the way they have always dreamed of – they seize the opportunity.“
For some of them it’s also a step up: most of the department heads, for instance, have not held those positions before.
“Of course advancement is a factor, but doctors aren’t rushing to leave their comfort zone to move to a city like Ashdod just for the sake of a promotion. The renewal, the innovation, the fresh model, and the amenities of the building itself, challenged the doctors and drew them in. Most of the department heads are doctors in their mid-40s, and they are coming here to develop their professional career, not their bank balance.”
They’re also taking a risk. Everything here is new and unknown.
“Life is the art of taking risks, and in life everyone makes risky decisions. When the doctors saw the management, the vision, the enthusiasm – they thought the risk was worth taking. They also saw the capabilities of Assuta – a strong, well-managed organization – and I hope we won’t disappoint them.”
As a private company, you are not beholden to collective agreements. Are you paying doctors salaries that are much higher than those in the public sector, in order to attract them?
“No, because we don’t have the luxury of doing so. We decided that the salaries would be good, but certainly not excessive. We aren’t able or keen to get involved with all the fuss being made over high salaries. I can’t even pay a third of the salaries I’ve seen paid to doctors in central-region hospitals. Some doctors had salary expectations that didn’t fly, and others who were in talks with us were offered raises by their current hospitals. In the end, a hospital needs to be financially stable, and we don’t have the luxury of paying the kinds of salaries which would leave the hospital in a deficit. If we are not extremely careful and measured with how we spend money – we will not be able to run a hospital.”
And this approach worked with doctors in all specialties?
“Anesthesiologists were a particular challenge (anesthesiologists represent a bottleneck in operating a hospital in general, and in operating rooms in particular; RLG). This field suffers from a shortage of doctors. The salary expectation of anesthesiologists in Israel is one that we cannot meet.”
And what about nurses? The shortage of nurses is even greater than that of doctors.
“We decided that nurses will earn the same salary as they do in the public system. We had an advantage, because there are already many nurses who live in Ashdod and work outside of the city. We’re also offering them improved work conditions: less strain, more personnel.“
“Recruiting doctors out of thin air”
Have you made mistakes along the way?
“Definitely. And there have been a lot of takeaways. The first error was at a national level – today, I would not try to open a public hospital without agreeing on the staff recruitment method ahead of time. The issue is complex, problematic, and not entirely fair to other hospitals.”
How is it unfair?
“You build a hospital, and then you need to recruit 250 doctors and 500 nurses. And where are you recruiting from? From a shortage. From a situation in which there isn’t a single nurse in Israel without a job, doctors are working in about three different positions, and everyone’s salaries in the central region are extremely high. You need to be recruiting doctors out of thin air. It takes 12-15 years to train a doctor. Similarly today, if the government is considering building another hospital within the next ten years, it needs to start training doctors and nurses that don’t exist yet.”
In short – there was no national planning here.
“No. And more than that – even if more doctors and nurses were added today, they would only be filling the existing shortage. We need to flood the country with doctors. It will contribute both to the lowering of salaries and the filling of the ranks outside the central region, as well as improving medical service and reducing the burden on existing doctors.”
So basically, you had to “pinch” doctors and nurses from other hospitals.
“Correct. But in a situation like this, when there is such a shortage of doctors and nurses, there was no choice but to pull doctors away from existing hospitals. Our conclusion is that human resources planning is desperately needed, and that Israel will need to think long and hard before it decides to build another hospital. Either produce more nurses or bring them from overseas.”
Are you serious? The situation is so bad that we need to bring in nurses from outside the country?
“It’s unfortunate, but if there’s no choice and Israel isn’t capable of increasing the number of nurses, it may be the only solution.”
How did we get to a situation where the state is unable to produce more nurses?
“Because the schools aren’t filling up, and the occupation is not a popular one. It’s a hard and exhausting profession. It’s a great vocation, but because of the lack of personnel, every nurse is required to work so hard that she doesn’t get to fulfill her purpose. I am convinced that the more we increase personnel, the more attractive this profession will become.”
“I refuse to accept the current state of affairs”
What will be different about this hospital?
“We asked ourselves what kind of hospital we want to have here, and then we decided – we want a community which has a hospital. That is to say that the hospital’s doctors will work in the community clinics and the clinics’ doctors will have the opportunity to work in the hospital. We have built a network of information shared between the community clinics and the hospital, in order to create continuity of care: when patients arrive at the hospital, all their medical information will already be there, and vice versa – when they are released from the hospital, their medical file will already be at the clinic. This prevents overtreatment, and will improve quality of care. In every ward there will be a case manager – a social worker, head nurse or medical psychologist – who will adjust all the treatments to each individual patient’s needs during their stay. When the patient is released, the continuation of the treatment will already be coordinated in the hospital, so that the patient leaves with everything they need, from prescriptions to advance appointments for further tests and follow-ups at the healthcare service’s clinic. This inclusiveness will lead to better treatment, less overtreatment, and a much more holistic view of the patient.”
And all the healthcare services are on board with this collaboration?
“We offered the model to all of the healthcare services, and all of them had an initially positive response, but unfortunately, at the moment only Maccabi (owners of Assuta; RLG) will be included as part of the model. I believe that with time, the rest of the healthcare services will have to join us.“
Give us an example of how this will actually work in practice.
“Take breast cancer, for instance: when the tumor is discovered, the question arises of what to do now. After the diagnosis is made and the pathology tests are complete, one needs to decide how to progress – surgical intervention, radiation, or chemotherapy. At this stage, many women fall between the cracks and are shuffled around between one doctor and the next, between the healthcare service’s clinic and the hospital, getting conflicting advice. With us, all these matters will be organized between the community clinics and the hospital. Our vision is that a city will have a head oncologist, a head cardiologist and other experts who are responsible for the entire process, and create medical policies which are shared by both the hospital and the community clinics. Furthermore, each patient will have someone managing the whole series of procedures they’ll need to undergo.”
And this is what attracted the doctors?
“It’s the dream of every medical professional, because what is the main problem of medicine in Israel? We have excellent doctors, some of the best in the world. Individually – every patient that comes into contact with doctors receives the best diagnosis and treatment that medicine can offer. The problem is that nobody talks to each other, and the people, the patients, fall by the wayside. They don’t know where to turn. Someone needs to integrate this whole field. And that is exactly our goal: we are creating a system in which you don’t need to run from doctor to doctor. Someone is taking care of you.”
What else will be different in this hospital?
“I’m not satisfied with the current state of emergency departments. Our ED will be efficient and uncrowded. Staying there will not be a nightmare.”
But that’s not entirely under the hospital’s control. Sometimes EDs are simply crammed with patients, and the hospital doesn’t have enough staff to treat patients quickly, in the best possible way. How exactly do you intend to overcome this problem?
“It’s true that EDs are overcrowded, but this needs to be solved through the right physical and human infrastructure, so the actual stay inside the ED will be very brief. It’s also true that, in general, there is a shortage of staff, but that is exactly what we’re investing in – because that is the bottleneck of every hospital. I believe that our principle of being connected to the community will help immensely, because when a patient comes into the ED and there is direct contact between the ED and the community, there will never be a situation where that patient is a blank sheet.“
The average wait time in an Israeli ED is 4-5 hours. How long will people need to wait in your ED?
“Under our model, the average wait should be 2-3 hours. It’s possible, provided there is proper planning. The status quo of waiting for hour after hour in an ED is just not right. It’s not fair and it’s not acceptable. We need to devote much more attention to this issue, because this is the bottleneck of the hospital. Inevitably, the better we get and the more manageable we make our ED, the more patients will come to us, creating more strain… but we will rise to the challenge.“
Maybe that’s not so smart, because you’re an urban hospital with a limited population.
“As I see it, it’s only a matter of time before people from outside Ashdod get in their cars and come here for treatment. When you know there’s a place with better service, which was built with patient welfare in mind, that doesn’t have beds in the hallways – you’ll go there.”
No beds in hallways – the very symbol of the Israeli hospital system? How can you commit to that?
“Personally, I find it very disturbing when people are hospitalized in the hallway. It’s not right, it’s not fair, and it’s humiliating.”
And it’s profitable – every bed in a hallway creates more income for the hospital, with almost no additional expense.
“True, and in my opinion there needs to be a law against it. The problem with beds in hallways is that only people who’ve had to use them really know what they’re like. Those who haven’t had to, have no idea.”
You must be alluding to all the politicians, officials and decision-makers who get VIP treatment when they’re hospitalized.
“Correct, and therefore some of these people are talking about this on a purely theoretical level, and they have peace of mind on the issue. With us, this will not happen. If we need to admit more people when it gets crowded, we have rooms big enough to comfortably hold an extra bed. But I hope it won’t come to that.”
Noted. And still one wonders – what will happen in winter, when occupancy rates exceed 120%, and even 140% in some hospitals?
“The health system’s winter overload brings with it the inability to thoroughly diagnose the patients’ problems, so they are hospitalized. If the ED were better and ran more smoothly, and also made an effort not to simply admit people – there would be much less strain on the medical wards.”
How does one create an incentive not to hospitalize?
“For example, switching over to a global incentive model for admitting patients – the hospital will receive a fixed amount of money ahead of time, regardless of how many patients are admitted. It’s possible, and in three years’ time I’ll show you that the care we give is more precise and cost-efficient, and our quality and patient satisfaction levels are indisputably excellent.”
Currently, a family can’t leave a patient in a medical ward overnight without worrying that in the morning they’ll find him with a dirty diaper, or suffering from untreated pain. People either pay to hire their own nurse, or leave their lives behind to camp out next to the patient.
“That’s true. There was a senior official once, who is now etched in my memory. When his mother was hospitalized, he wouldn’t budge from her bedside. Of course, if there were enough night nurses, this wouldn’t happen. It would be enough if there were one nurse checking on each patient once overnight – and this could make a significant difference. That’s what we’re aiming for.”
How does this fit in with the “silver tsunami” that Israel will soon be facing?
“One of the important things that the health system needs to start providing is home care, including home rehabilitation, assuming that the patient has a support system. Today, someone can have surgery for a broken neck or leg and end up staying in the hospital for months, simply because she doesn’t have that support. Sometimes the patients are hurriedly handed off to their families, so that they’re the ones who have to deal with the hassle. But if you plan in advance and don’t dump it all onto the family, but rather arrange a home rehabilitation program, you can save massively on expenses and days of hospitalization. It will never be the case that we force an aging, sick person to go back home. We will arrange ongoing care for all patients from all the healthcare services, either at home or in the nursing ward. During the next phase, we want to add a geriatric rehabilitation ward.”
“There will be no private practices”
Doctors and nurses from different hospitals, with diverse organizational cultures and working methods, will be expected to work together. How will you get them on the same page from day one?
“In my opinion, this is actually a golden opportunity to create good organizational DNA from the word go. We are bringing staff from many different places, but we have the ability to turn this into a melting pot. I think it is much more difficult for the director of an existing hospital to make sweeping changes. But the fact that we are already talking about service with a smile at the first meeting… people love it. People simply want things to be better. We want a place that creates a positive atmosphere.”
Can people really change years-old habits?
“I believe that people can change their behavior if you give them a different framework. If you take people who are typically aggressive to a grand concert hall, they will behave differently. Assuta has established a School of Professionalism, which has already trained thousands of employees. We have invested 15,000 cumulative working days in this. We talk to them about integrity, empathy, and communication. We have taught them to greet people, and everyone attends a cultural competency seminar. Ashdod’s population hails from 99 different countries.”
This will be the first hospital in Israel which is publicly funded, but privately owned. Does this increase the risk of financial considerations taking precedence over clinical ones?
“We are a limited company and bound by all the corporate laws, and this is indeed the first time a private company has operated a public hospital. We are aware that this is a kind of experiment, and that the Ministries of Health and Finance are watching us to see how we will run this hospital. There will never be a situation where we opt not to do something due to financial considerations. It’s important to understand that all hospitals are managed in an economic way, and we won’t be above the law. We will be evaluated against quality indices, there is governmental supervision and we are under the control of the healthcare services.”
What about conflicts of interest?
“It will never be the case that a patient from Assuta Ashdod will be sent to Assuta Ramat HaChayal. And we know that we are under a microscope.“
But some of these doctors are currently surgeons at Assuta.
“True, and they will continue to perform surgeries there for residents of Tel Aviv, Jerusalem, and other cities. Not residents from Ashdod. The doctors came with the understanding that their day job is to eliminate the long queues that push people to private medicine in the first place. It’s a question of management and leadership. We are putting into practice the many lessons that have been learned from the current system. Our conversations with doctors have only clarified our intentions further, and they have chosen to come here willingly.”
So there won’t be any private practices at Assuta Ashdod? We aren’t going to discover that you have a ‘Class Clinic’ where you secretly perform private plastic surgeries, like what happened at Sheba?
“Without question – there will be no ‘Class Clinic’ and absolutely no private practices.”
“Israel needs more hospitals”
There was huge opposition to building this hospital. The main concern was that it would deal a hard blow to the neighboring hospitals which have been serving Ashdod to date – Barzilai in Ashkelon and Kaplan in Rehovot.
“These are not legitimate concerns. We are talking about a situation in Israel where the southern region is short hundreds of beds, and the doctor-to-patient ratio is the worst in the country. Even if 300 beds were added to Ashdod, which would later increase to 700 beds, you still wouldn’t have one vacant bed at Barzilai or Kaplan, and obviously not at Soroka. It will only have a positive impact on the residents of the south and the general population of Israel: in Ashdod, 250,000 residents will now receive a higher level of care. On a national scale, we have added dozens of new positions for interns in fields where there is a staff shortage, and clinical fields have been added for medical students, which will allow Ben-Gurion University to train dozens more doctors. It is an incredible engine for growth.“
Does Israel need more hospitals?
“Absolutely. In another ten years the hospitals will run out of space. We will wake up and realize that suddenly there are no more beds to hospitalize older patients with complex illnesses. We can’t stop the population from growing or aging, or the fact that an aging populace comes with a high morbidity rate. Someone needs to set up the right infrastructure, starting today. When you build a hospital, you’re building it for the coming 100, 200, and 300 years. From the moment the decision is made to build a hospital, it takes roughly 7-10 years until it’s ready to open. That’s why the country is facing such a dire situation in this sector.”
But why do we need to build new hospitals? Why not expand the existing ones?
“There is the issue of the optimal size for a hospital, which is between 700 and 1,000 beds. Beyond that, it’s simply too big. Additionally, the good thing about building a new hospital is that you get to plan everything from scratch. There hasn’t been a new hospital built in Israel for 40 years, and when they did build one 40 years ago (Clalit’s Carmel Hospital; RLG) it was an entirely different medical era. In those days, to open a hospital you didn’t need to install an entire internet system, digitized records, and advanced equipment.”
What’s the next step?
“Heart surgery. Cardiac surgery is currently being performed with new technologies, minimally-invasive procedures, operations that do not require all of the infrastructure that was once needed. As we plan to add another 150 beds, we will want to expand the number of oncology beds. Generally speaking, wards are only opened if deemed necessary on a national and local level. If, for example, the number of children with cancer in the area is less than 50, there is no reason to establish a pediatric oncology ward in Ashdod. The same applies to neurosurgery – in recent years, licenses have been granted to open new neurosurgery wards, but in today’s State of Israel, where there are not enough professionals in the field, there needs to be national consideration and policy, and it’s worth thinking twice before opening another ward. These days there is a global trend towards reducing the number of wards in order to enable specialization and improved standards in those that already exist.”
Where will Assuta Ashdod be in another 50 years? What is the vision?
“The vision is to be Israel’s Mayo Clinic (the leading medical center in the U.S.; RLG) – a combination of high-level service and excellent quality medical care. The doctors here will be full-timers who only work in the hospital, are paid appropriately in accordance with their output, and partially participate in the profits and revenues of the hospital. It is possible.”
You’re making ambitious, perhaps even grandiose statements about a hospital that has not even started work. Do you sense that people wish you well, or that many are just waiting for this ambitious hospital to fail, or turn out to be exactly like all the other hospitals?
“I believe that, at the end of the day, people truly do want to see the good in things. We are creating a new model here. It’s clear to me that the Ministries of Health and Finance are waiting to see if it’s possible to successfully run a public hospital with the atmosphere of a private one. Everyone is eager to see how this creation will turn out.”