Alliance for Patient Safety

Boaz Lev:

Thanks to the committee and thanks to those present. I think that it is an important discussion and thanks also for the criticism. I believe that we agree with 99% of the matters you have said. We shall shortly show what has been done; however really, it is as if you have spoken out of our mouth. First of all I think that we are not here in some kind of conflict. I think that everyone that is sitting here, and the public, wants a better health care system with higher quality and this is the reason that we are here and the reason that I am in the role together with my predecessors.

I want to say another thing. We are not representing nurses, we are not representing physicians, and we are not a professional union. We represent the public interest. That's all. The objective of the public interest is to improve the quality of the treatment and the service, and the purpose is the improvement of the quality and safety in the first place. We want that there will be organizational learning, and we have talked about it, personal learning as can be, and also to be a body which clarifies facts and to get structural evidence for launching a disciplinary process, because it is part of our role as well, to transfer it later to the disciplinary court unit in cases of severe negligence.

Another purpose not mentioned here, but I see it as most important, is the implementation of the service awareness, empathy and compassion among the treating personnel and the creation of understanding and containment between the health care personnel and the patients. Within this framework we encourage direct discourse between health care personnel, management and patients and we are acting a lot in order to promote this issue.

Really, in the tiniest of a nutshell about the work of the commission; we are getting complaints, we are getting reports about exceptional events and we also take appearing news from the media and we start to examine them. We are hearing the complaints people bring forth and listen to the defendants and we clarify it in different ways, whether by means of opinion, whether by means of an investigation committee, or in any way that we see effective in order to arrive as soon as we can to the root of the truth and this is pretty complicated because time always passes, there is protection of immunity and protection of health care personnel who want actually to defend themselves and do not provide the complete information in a timely and generously manner, and we wish to arrive at a position in which these matters will be confidential and this information could be received and go down in search of the truth; that's the objective.

At the end of the examination we reach conclusions, both, personal and systemic, we can refer to the disciplinary court. We can recommend on corrective measures and we do it almost in every case, and receive also at the end feedback from the organization about what they have done in order to correct the any ill behavior.

A few numbers about our scope of activity and you can see in these that changes had occurred in the numbers, that are fundamental changes; we have about 1,000 to 1,400 applications per year. It changes from year to year; there is no some kind of a fixed funnel. There are about 50% and up to 60% of the applications are resolved within 4 months, and 70% of the applications are resolved and closed within one year. The committees' time frame was 20 months in 2011; today it is 7 months on average. We conduct 80 hearings per year. The number of complaints submitted to the Disciplinary Court unit in the last decade was 226. It is not really a high improvement, but the numbers do not tell the entire story. There are very simple cases, there are also very complicated cases and it is not a good yardstick. Out of the above, 146 complaints were due medical negligence and 80 complaints following criminal indictment. The moment a Court of law rules that someone is guilty, they return to us and they pass a complaint process and being punished. The total number of indictments in the last decade was 199 indictments, out of which 130 were due to medical negligence and 60 indictments following criminal indictment. There are suntil 57 open cases in the Disciplinary Court Unit. Concerning permanent suspensions, all as a response to questions; since 2007 there were six of those, each one following a criminal indictment, due to drug trade, murder, rape; these were the cases; each one had passed through the legal proceedings. When a suspicion arises about a violation, we refer it to the police and the Attorney General's prosecution and many times they say to us "proceed" or "do not proceed with the investigation, because we are entering into the picture", and we step back in order not to disrupt the investigation proceedings. As for one of the cases that had been introduced in the previous session, it is parked at the Attorney General's prosecution, not with us.

Mistakes, errors and negligence had occurred in the past and will occur in the future, regretfully. Even the Commission is not immuned from it. Can we possibly be wrong? Of course we can!  Were there cases in which perhaps disciplinary processes should have been acted upon and not taken? No doubt there were cases that complaints were submitted and perhaps it would have been right if they were not submitted? Yes. But I must say, on behalf of all the activity of my predecessors in the position, as I am relatively here only a short time, it was done for its own sake, without prejudice and without the intervention of government bodies; although it is not very regulated, and the statement is correct that on the complaint the Manager General of the Ministry of Health is suntil signatory. We see in this as an autonomous problem.

But only in short, a few events in order to give an example of what we dealing with. Some of the cases we handle are sad; they generally are all sad. No one comes to us out of joy. It saddens us too. We are all people and we care, and it is tragic, and it causes us to lose sleep at night. Some examples, a kid comes to Emergency Room with a suspicion of throat inflammation due to epiglottises, it is a disease that from which one could easily suffocate. The kid, after not a lengthy process in Emergency Room, is discharged for home and dies. He came back and died. As a result of this event, some standards for exceptional results in x-ray imaging were established. There was a problem in the identification and transfer, and rules were established for transfer of information and the responsibility of medical health care and nursing staff. And in the disciplinary aspects, complaints were lodged against the Emergency Room physician, the Ear – Nose & Throat physician and the x-ray physician, as we thought that the chain was improper in each one of the points in the chain of events.

The sad and horrific case of Ofek Taub, who was ventilated with CO2 instead of oxygen; Recommendations were formulated to prevent reoccurrence of such events. It had been examined in every licensing and accreditation process of the hospitals by means of the supervision and control array in our medical administration; a circular of the patient treatment array has been distributed. The Ombudsman's recommendations at the level of the hospital were implemented specifically. In the area of the disciplinary process, first of all the appointment of the Hospital Director to the position of Head of Medical Administration in the Ministry of Health was cancelled. It means that it occurred when he was a candidate for the position. It had been recommended to lodge complaints against the involved physicians, a process that had been suspended following the criminal investigation. The Attorney General's prosecution is conducting hearings in anticipation for indictment submission. Have we excelled in this event? The answer is no. It took time and we are looking backdepartments and doing — it is all part of events that had happened many years ago. There were deficiencies back then, and obviously there are deficiencies today as well. Are we in a process of improvement? I think very much so.

Additional subjects that were placed on our table; babies deliveries performed at home which ended in tragedy, low standards abortions, surgeries of obesity, responsibility of the persons on duty. On this matter we didn't have too many complaints and grievances. A physician not showing up; he is called, he is contacted at home. He doesn't wake up and he is not coming out. We have quite a few complaints and disciplinary processes against such physicians. It is almost automatic. A physician not showing up, because physicians do make mistakes; however, negligent physicians, by the mere fact that they are not arriving, and thus committing acts of negligence – it is unforgivable.

In all of these cases we have drawn organizational lessons and conclusions, and circulars were distributed in these matters. I don't want to make you weary. Controls were conducted, licenses suspended, complaints were lodged against directors, against physicians and against nurses and recommendations were made about structural changes of units. The list is long. As of today every such thing enters the norm of routine investigations. There is today also a JCI array that examines and grants accreditation to the hospitals and these issues are entered and examined specifically.

We have prepared a Memorandum of a Law which purpose is to resolve the functioning of the commission, and the Ombudsman. It already appears in the State Comptroller's report. Also In 2004, in the Knesset report and in the follow-up of the State Comptroller's report in which, first of all, the autonomy of the Ombudsman is emphasized, as well as its investigation powers. Today we have no power of investigation whatsoever. We are very much depending on kinds of good wills and intentions. I must say that we are receiving a lot of good will, both from the investigating physicians and the cooperating physicians, because some of them are not trying to conceal, some of them say "we have made mistakes, we have neglected, we have learned something from this case", and we are conveying it later for further handling.

And the main thing; today the process is terrible and horrific. That is to say, we receive a complaint; we are clarifying it within this or that time frame. Later it goes through the quasi – legal food – grinder and a process of a complaint in the Court of law. And it is not their fault. It is a process like in the Court of Law. It may take years, and at the end we get a result after three years; two-three years from an event, which nobody remembers the event any more, except the family that suffered; and there is a warning for the sake of the matter, a reprimand, a temporary suspension of a month or two or three and even a suspension — it is far off and not enough, and it doesn't do the job it should. Most of the matters are not in the area of the long suspensions. Most of the matters are really in between. And we think that the commissioner should have the power to order processes that are corrective processes, that are processes that force a physician or a nurse to undertake training, to work under terms of restriction, to limit their promotion. All these things are not in our hands today. Apparently today, either you are acquitting or you send him for a complaint process and this does not satisfy the —

In the few events in which we could activate any judgment, I would call it some kind of manipulation. We have asked the hospital in which the physician made an error to call the physician and give him a role in the safety array, in the area in which he made the error, and he will enjoy the process and learn. And we want to distribute it. It has been a kind of a pilot in order to see how this thing works, and it does work. It works well.

There is another issue, and I understand, I understand my colleagues, my friends and their pain and lack of trust. The lack of trust was not invented on this table. The lack of trust in the system is a problem. We are trying to see how we cope with this. One of ways to cope with it is transparency, to create more transparency. Transparency you create in few forms. One of the forms for example is to include a representative of the public in the processes we are undertaking, in those units in which it is important that our integrity will be seen, seen and understood. It is done more and more, and we want to make it a standing method. We also publicize today; the previous report of the former commissioner was issued about 100 cases of committees with their relevant and professional conclusions. We are justifying files and we are recording them, and I shall not tire you more with this issue; however I think that transparency is a very very critical matter.

I am talking a lot with families, with complainers. I am trying to clarify because many times the submitted complaint does not play the music of the real complaint behind it. In all my sessions and my conversations with complainers and those they complain about I must say that I have learned something that did not receive the proper expression in the paperwork that we receive. Therefore it's part of the work.

Yes; it is important that the commissioner will be a physician. I know that there are different opinions —

Call:

Definitely not.

The Chairperson, Karin Elharar:

No, we are not managing —

Boaz Lev:

I know that you think no, but I think that yes. We think that he has to be a physician in order to understand the material we are dealing with. This is professional material, complicated material. It is also necessary to know the professional literature, as well as the norms and the regulatory space in which we work. Also the topic of the circulars issued in this matter; It is like an engineer will sit at the head of the Bar Association,. It is not appropriate, it is not appropriate to the space — and therefore it is very very important. Important, maybe even more so and here I also know that there are contradictory opinions on this matter. In our opinion, and this is also the opinion of the Ministry of Health and my own opinion, of course. The involvement of the commissioner in this space of safety and quality of the medical administration, that does the audits day in day out, and issues the control reports in order that we could provide an immediate feedback to their controls, that we should be close to the licensing bodies, to those that grant and revoke the medical licenses, to those that give licenses to the medical institutions. We have to be there; we want to react fast, otherwise I believe that this disconnection could be dangerous. Not only is that dangerous; the removal of the commission from the Ministry of Health will bring about again a culture of concealment; it will lead in fact to cover – up and concealment because —

Amiad Taub:

It will in fact continue the present situation; concealment, cover-up, this is the current situation, no?

The Chairperson, Karin Elharar:

I want to ask two questions.

Boaz Lev:

I am finishing in a minute. We have no punishment power. We are not the punishing party. The punishing party, incidentally, the one that sets the rules, is the disciplinary unit which recommends, and the Minister of Health who delegated the authority to a retired judge; at the present it is Schtrasnov, who has the power to decide the Court ruling and the sentence. That is to say that he can decide the court ruling and the sentence. The number of complaints does not reflect … and neither the number of applications because —

The Chairperson, Karin Elharar:

Just for understanding; the Court ruling and the sentence are the legal process?

Boaz Lev:

The disciplinary; I must say that we see here only the tip of the iceberg of the applications, since most of them are clarified at the hospitals and the health care clinics. They are clarified there, they are getting there and we really have arrays which are dealing with quality in a separate manner from our activity. We see only the tip of the iceberg. The clarification processes as of today, as long as we will not promote the law, take a long time. Involved in them are lawyers and interests. Not once the disciplinary court unit is of the opinion that there is not enough evidence for severe negligence, even though when we think that it is necessary and a must that a complaint is submitted, it will not stand in the disciplinary court.

In recent years, as I have said, a meaningful change has taken place. In 2004 the Knesset Research and Information Center issued a report which really resembles the State Comptroller's report; following, and only on a large scale, most of the complaints do not arrive to the examination of the Ministry of Health. It is true. The larger part, as I have said, is conducted in the health care clinics, and it is good that it is so, because they are the assembly floor and they need to correct it.

There are no criteria for the decision on the manner of investigation; not true. We have clear and written procedures as to how we conduct the investigations and what is the procedure. The composition of the investigation committees – I agree that there should be a representative of the public. I think that it is essential for transparency. The duration of the work- we have talked about it. I think that we have shortened it considerably, but suntil not enough. Transparency – I have spoken.

Beazalel Smotrich (Habait Hayehudi):

Is the duration a function of your manpower? What are the vectors that will finally influence it? Is it really crucial?

Boaz Lev:

There are many vectors here. Lawyers are involved in the process, meaning that the rights of the defendant are protected for all practical purposes. Therefore it requires coordination. From time to time and decreasingly so we have unwillingness of physicians to serve in the committees and we overcame that also, because at the present we compensate them. It solved part of the problem and the committees, at the end, have considerably shortened their operational time frame. Suntil, due to the problem of immunity we cannot approach immediately and investigate because we have to protect the rights of the defendants. There is a problem in that, because we lose part of the truth. Part of the ability to dig into the root cause; it is very important, and the removal or the keeping of the commission will not change anything in this matter.

In summary I want to say one thing. The citizens of Israel deserve a good medical system. Sitting here is a former Minister of Health. She knows the quality of the medical system, we all know that tragedies occur and mistakes occur and errors occur. It is sad for all of us, but at the end when a physician gets up, a nurse, a medical team member, he gets up to treat patients. Most of them do it with integrity, by professional standards and with compassion.

The Chairperson, Karin Elharar:

It is clear.

Boaz Lev:

Not all of them, not always. Thanks.

The Chairperson, Karin Elharar:

Clear, thanks. I want to ask two questions before I give the floor to the Knesset members. Is there information sharing between the hospitals, that is to say, an event occurs, conclusions are drawn, is there any networking to all t —

Boaz Lev:

With your permission, Dana, who is in charge of the patient safety in the Ministry of Health will say a couple of words.

The Chairperson, Karin Elharar:

Just yes or no at this point in time; is there?

Dana Arad:

There is.

The Chairperson, Karin Elharar:

During the process, to what extent the families or those that complain are updated? Are they updated in any form?

Boaz Lev:

Right from the beginning; it is to say along the entire way, as of today —

Call:

On what they are updated? On what?!

Call:

In the last six years we have not met the Ombudsman even once.

Boaz Lev:

I must say, first of all, that a change really took place.

The Chairperson, Karin Elharar:

Since when does this update exist?

Boaz Lev:

As of today? There is no —

The Chairperson, Karin Elharar:

No, you said in recent years. When did the process of family updating start — ?

Call:

I can simply explain the process.

The Chairperson, Karin Elharar:

Just a moment, sorry Sir, you too; it is a committee; it is not a multi – cultural discourse. You will get a permission to talk, and then talk.

Gideon Zurielli:

Because the time frames had been shortened considerably in the recent years, as Boaz said; in 2011 it was 20 months; today it has been shortened to 7 months. Most of the cases are clarified within a year, and therefore we arrive at a situation in which we make contact with the families even before there is a complaint, because most of the cases that are clarified with us are actually a result of a report from the hospital, not a result of a complaint. So we proactively make contact with the family —

The Chairperson, Karin Elharar:

Is it in certain type of cases?

Gideon Zurielli:

They are asked to come and testify and tell the story, and when the committee finishes after 7 months they also receive the report.

The Chairperson, Karin Elharar:

And when there is a complaint from the family?

Gideon Zurielli:

The same thing, also; it comes from their side and they are invited —

The Chairperson, Karin Elharar:

During the process?

Gideon Zurielli:

They are invited to appear before the committee; the committee finishes after few months and they receive the report.

The Chairperson, Karin Elharar:

It was not my question. They appeared, said what they had to say in the clearest manner; the process is prolonged, and there are few months that have passed since the complaint and its hearing —

Call:

During the investigation process.

The Chairperson, Karin Elharar:

Yes, is there any phone call? Any contact person? Anyone? Or simply the commission disappears into the horizon and they return.

Gideon Zurielli:

The answer is as follows; there is no formal reply to this topic. On the other side, the person that manages the commission bureau, who has legal education, and knows these cases very thoroughly, her phone number is given to each applicant and she advises regularly on its status.

Yael German (Yesh Atid):

It is not an answer.

Call:

There is a secretary that if we chase her, she will answer.

Yael German (Yesh Atid):

No, they are those that t —

Gideon Zurielli:

No, no, no.

Call:

The Committee is with us. Three years you did not bother to call and meet.

Yael German (Yesh Atid):

Then the answer is no.

Call:

You didn't bother. You were the Deputy General Manager at that time. Aren't you responsible on t —

Boaz Lev:

The truth; there are things that must be improved, clear and simple.