The israeli experience with hospital preparedness to terrorism

The Israeli Preparedness in The Tel Aviv Sourasky Medical Center, An adaptive mechanism to respond to unexpected events and disasters.

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The Preparedness in The Tel Aviv Sourasky Medical Center: An adaptive mechanism to respond to unexpected events and disasters. Taipei Medical University. Alexander B. Rubashkyn. Abstract. The systemic approach toward the uses of the resilience engineering nowadays is seen as a novel mechanism to provide safety in health delivery shifting the paradigm of understanding about the safety as the absence of undesirable outcomes, to the variability of the performance as a common feature of the holistic intractable systems, leading to understand beyond the linear thinking how the systemic and dynamic approach can be assessed in order to cause the system to obtain robustness and resilience to alterations. Tel Aviv Sourasky Medical Center has started the process to set the contingency toward hazard using a different way to understand the organization, in this case looking and the communication network and the Empowerment through microsistemic leadership and resilience training was introduced to emergency team leaders of all disciplines. Focal subject matters included proactive planning, problem-solving, shifting the regular way of proceed over different horizontal and vertical ways of communication, coping through and stress-management techniques. The outcome of this process

was manifested in an operation and people orientation supporting a more effective and compatible emergency management toward the holistic understanding of one health care organization. Keywords: Resilience engineering; Preparedness, Dynamic Systems; Disaster Responsiveness; Emergency Prevention; Disaster management; Terrorism. Introduction. Unfortunately Israel has assumed the unwanted role as a world leader in developing medical technology and planning to prepare for catastrophic situations and its innovations are being studied and disseminated to other countries to save lives. The understanding of the Israeli Emergency Health Care system as a complex adaptive system forced during its history and the knowledge about how the Israeli structures had to be adapted to several stages of organization due to the external agents as potential hazards, like wars, confrontations, variable political situations, environmental hazards (biological, chemical attacks), and other multiple elements as natural hazards and economic crisis, furthermore the level of uncertainty about the future, and the sustainability as a whole "country" is an important key, to understand how despite of these explained continuous hazard, this country had overcoming these adversities and has becoming today in an important global market with a vibrant economy . The Israeli Health System as all the Israeli unities has not been immune to this continuous uncertainty, however, the current status of Israel have allowed to manage in several occasions several critical stages during the history; The continuous learning and the self adaptation


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in this complex environment have permitted that by mean of the resilience approach the Israeli Health System be functional, efficient and organized even in the worst situations. General Background [1] Israel is a country that was establish around 1948 after the world war II, is a small country at the eastern end of the Mediterranean, bordering Egypt, Jordan, Lebanon, Syrian Arab Republic, and the Palestinian territories, Israel, with area of 20,700 km2 have around 7,8 million of inhabitants, 75% are ethnically or religiously Jewish, and 20,6% are Arab. Israel terrain consist of the Negev desert in the south, low coastal plains, central mountains, and the Jordan Rift Valley. Israel has low natural resources, limited freshwater, and arable lands as the general environmental concerns. Immigration has played a critical feature in the demographic of Israel, when the state was declared in 1948, its population was 873.000 increasing with large waves of Jewish Immigration, from European and Arabic countries. The median age of its population is 29,3 years, the life expectancy is around 82,4, which is one of the highest in the world, and the income in term of GDP per capita is around 28.000 USD. 92% of the Israeli population lives in urban settlements, 99% of the population is literate. The military service is mandatory for Druses and Jewish (36 months), for other ethnicities is volunteer. Israel is a parliamentary democracy, the country doesn't have a formal constitution,

but follows the rules of the Knesset, and the laws adopted from the English Common Law. The country is divided in six administrative regions. Israeli Health Care System Health care services in Israel have been developed over the past century by voluntary health plans originally called sick funds, non-profit institutions the establishment of the State of Israel in 1948. Workers’ associations established the first health plan in 1911 to provide care to workers and their families and to employ immigrant doctors. [2] The nature and the achievement of the health care system in Israel stem, to a large extent, from its foundation in organized social arrangements as well as a general consensus that society as a whole is responsible for the health of its citizens. This guiding principle has been reflected in the structure of health services in Israel, combining state activities with those of the voluntary health plans. Ministry of Health (MoH) The MoH has the responsibilities to provide health to the Israeli population and managing the health delivery. It sets the policies in the fields of health and medicine regulation, and is in charge of planning, supervision, control, licensing, and coordination of the services of the health care system. [2] Public health services Israel’s public health services concentrate on the healthy individual from the personal, community and environmental preventive medicine perspectives, through assimilation of the innovative concept of health promotion.


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These services are committed to promoting health and disease prevention among the citizens of Israel and include family health stations, health services for school children and district health offices, as well as professional administrative staff. Seven district health offices are responsible for the coordination of public health services and medical operations in each region, collaborating with all health care entities that operate in the region. Hospitals Israel has 28 general hospitals (11 are governmental, 8 belong to an HMO (Health Maintenance Organization), 6 are under public not-for-profit ownership and 3 belong to a church or mission), with 15579 beds around the country. The overall bed to population ratio in 2009 was 1.94 per 1000, although the ratio varies widely between regions. In January 2012, there were 1123 emergency department beds, 436 operating theatres and 349 beds for rehabilitation. Annual bed occupancy is 95% but there are large variations between departments: ophthalmology has the lowest at 57%, venereal and dermatology has the highest (126%), and most critical departments for emergency situations operate at near or above full occupancy all year round (105% in general intensive care, 111% in neurosurgery, 97% in orthopedics). [2] Understanding the Resilience, The Israel Kibbutzim and the Health Care Organizations. Hollnagel [3], [4]. in its works in how to achieve safety, understanding the complexity system, and focusing in the safety by design as a mechanism to achieve a well functioning learning from the performance fluctuations.

In this case he defined the systems as tractable or intractable in the way that the tractable ones are the systems which can sustain relatively the performance stable, and intractable the ones which can not have stable performance, the first one are considered as mechanistic elements, where its independent action can be settled and the whole activity can be constrained in a performance window, where the system does not change during the actions over it, this pattern allows to establish standards or norms. The intractable systems are the ones which have inevitable variability where the performance never can be constant as one machine, because in this case the behavior is within a holistic system. This behavior can be explain in the way that the human learn continuously over the outcome, and during the action, can react and anticipate a future action with the knowledge acquired, on the other hand, the human have flexibility in its performance, facing the actual demand of situation, following this idea, a human can use a procedure and suit it in the context of the current condition, by last the human has the ability to know sometimes when something is going wrong, and can correct it applying multi approach overview. According with Hollnagel definition of resilience [3] he says that this is a property of a system to adjust its functioning prior to, during, or following changes and disturbances so that is can go on working even after a major mishap or in the presence of continuous stress, as well, accepts a constant sense of unease and remains sensitive to the possibility of failure.


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The word ‘resilience’ is becoming important and used nowadays, this terms is replacing the term "preparedness” which is the quality of respond to face undesirable events, several examples are now all over the world from the 9/11 in New York, the Hurricane Katrina and 2004 Tsunami, and other are useful to understand and assess the response toward the crisis. The UNISDR, United Nations International Strategy for Disaster Reduction, has been interested in developing the ideas of resilience more than preparedness. [5] The UNISDR has defined the Resilience as ‘The ability of a system, community or society exposed to hazards to resist, absorb, accommodate to and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions. Determined by the degree to which the community has the necessary resources and is capable of organizing itself both prior to and during times of need.’ UNISDR Toward this definitions and understanding the Israeli Exosystemic, Mesosystemic and Microsystemic overview given initially. The Israeli system has been settled in a complex environment of hostility, an environment framed in a complex political, geographical, economical and religious situation, this in turn has allowed to Israel in different areas to establish several mechanism of response to uncertainty. One of the elements which characterizes the resilience is that the performance conditions are underspecified, so the individual and the organizations have to adjust their performance to the current

situation, In Israel from the establishment as a State defined by the UN after world war II the organization were starting to be settled in the uncertainty, e.g. the psychological resilience created due to the stress suffered by the Jewish population after the holocaust, and the continuous learning about the recent history of the European Jews, gave to the new immigrants who started fled of Europe during anti-Semitism in Europe, the ability to adapt its actions focusing more in how the set reliable organizations as militia, health care, schools, farms "kibbutz", more than the outcome, this can be supported in the way as to many areas in western Israel were depopulated and the performance and standardization it self was not the objective, the objective was to establish a functional society, toward the kibbutz, which were socialistic based farms focused in give work and the same time food bringing sustainability to Israel during the uncertainty of the 1940 and 1950 decade [6], those kibbutz were very important in the establishment of the State of Israel as we know, this model was focused in the collective work, collective leadership, using the socialistic thinking facing a systemic auto-sustainability. Those kibbutzim were settled all over the country in arable terrains as a pattern units of work, socially linked without a certain centralized structure, toward socialistic approach, and the democracy as the key element to build resilient communities that have faced and overcame hostility during the following half century. The human organizations are often intractable whenever the variability is a feature of the general and individual activity, so in this case the second element described by Hollnagel, the resilience shows that the adverse events can not be


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attributed to a breakdown of a component of a system, the adverse is understood as a result of unexpected combinations of normal performance variability or a inadequate adaptation to cope with the real world complexity. The other characteristic described by Hollnagel says that the safety in one system can not be seen in hindsight, error tabulation or calculation, because it fails in the linear thinking, as well the safety management can no be always reactive "act once the event is presented", the proactivity expressed in the safety II, faces the creation of resilience, or "resilience engineering" as the ability to create processes that are robust but flexible, and can face events even in stress or big disruptions. The Israeli kibbutzim modeling of farm and society fit in this third Hollnagel principle as long as the activity of the Kibbutz is more proactive than reactive, this can be supported in the way that the Kibbutz settled in a democratic leadership and a distribution of the world according with the individual capabilities allowing to the individual to follow its knowledge to improve the use the resources optimally and proactively in the face of political, military and economic pressures. The outcome or performance is not the main objective in one Kibbutz; the objective is to establish a unit or microstructure well integrated, and functional, even in the worst panorama. The kibbutzim could explain why the Israeli people is better positioned to feel and manage the environmental changes, its social structure have an special arrangement which was focused in the equality, the emotional involvement who allowed to understand that unity is

strength, the communal goal shared by each individual as well keeping clear the objectives of these kibbutzim. The errors identified when an external attack hits each Kibbutzim fibers are not managed isolated, they are structurally analyzed to assess and evaluate the why the structure allowed the Kibbutzim were vulnerable. The ideology of shared work, equality, and self-sustainability, in addition to the concept of pooling on uncertainty and strengthen the dynamic process and the interrelationship, was given by the concept of Kibbutz, provided the Israeli society which came from diverse thoughts, ideologies, races, origins, thinking of teamwork and work in communion directed towards the same goal, giving each individual the ability to became diversified leadership which face uncertainty, this kind of leadership can be metaphorically explained describing the behavior of the shared leadership in the shoal, which is a collective grouping of fish that use the shared leadership, communication, and systemic to address the myriad of unknown risks in the oceans. The shoal mechanism of defense facing the ocean threads is a mechanism used in the nature to overcome obstacles, this type of dynamic organization analogue to kibbutzim allows the fish to keep the functionality using biological mechanisms of communication and interrelationship using the transitional and dynamic leadership, making sure that each unit have the knowledge about how to manage the uncertainty using escape mechanisms, that at the same time warn their neighbors creating a synergic domino effect to face dynamic threats.


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This sinergic effect make that the organization manifest a nonlinear deformation leading to a more adequate risk management, making that the structure be fully dynamic, so, regardless of the performance itself, which really makes this unit fully functional is the ability to handle stress in extreme conditions, we can not have a rigid and hard system, that addresses the dynamic threats adequately, our structure must be dynamic as the environment is. Thus, the Israeli thinking as a whole community turns toward the management of the situation facing the current situation learning from a enriched past and continuously improving the connectivity through communication channels, leading to continuous improvement of the process as a whole. Having this previous knowledge of the current thinking developed in the Kibbutzim, and understanding this model of thinking as a Shoal, It is going to proceed explaining the experience of the Tel Aviv Sourasky Medical Center facing challenging scenarios such as suicide-bombing as mass casualties, biological and chemical disasters. The Hospital Preparedness for possible nonconventional casualties: The Israeli experience Case of Study: Experience of Tel Aviv Sourasky Medical Center. During last decade after 9/11 hospitals and health authorities in Israel have been preparing the medical response in case of various mass terror attacks. [7]

Knowing about the experience of Tel Aviv Sourasky Medical Center in treating suicide-bombing mass casualties served, in the time leading up to the war in Iraq, as a

platform for launching a preparedness program for possible attacks with biological and chemical agents of mass destruction.

In this study [8] was assesed, a method for disaster mitigation called Quarantelli's criteria following the microstructure of the hospital including human behavior expert, the interactive management of the crisis, and contingencies toward chemical and biological attacks. The focus of the authors was not addressed toward the resilience engineering, but the way how they assess and implemented the methodology and the contingency and mitigation of the potential hazards, can be seen as an close approach of resilience engineering.

A stratified assessment of needs, identification of unique dangers to first responders, and assignment of team-training sessions paved the way for program development. empowerment through leadership and resilience training was introduced to emergency team leaders of all disciplines. Focal subject matters included proactive planning, problem-solving, informal horizontal and vertical communication, and coping through stress-management techniques.

General Background.

The recent increasing threats against Israel, coming from several extremist and fundamentalist political and religious groups, and governments had settled in the Israeli government and in general in the Israeli population a common awareness and increasing attentiveness about the possible hazards and the possibility of changing scenarios which is not something new in the Israeli and Jewish history, as already was explained, called for updating protocols and continuous training.


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The political arena in Israeli territory show the need of understand the impact of non conventional weapons; in previous times, the transition from isolated frequent, mass casualty, suicide-bombing terrorist attacks, characterizing the present wave that begins in the 2000.

Preparing toward a eventual chemical and biological attack or casualties, in wich hospital staff and their families at home might be exposed to this hazard, called for contingency plan that would evolve from the existing emergency program and relate to large-scale multidimensional emergency management.

The presentation of these hazards require a different approach, as long as we need to integrate a response process with not known variables, as the medical response, training in managing the biological and chemical risk, availability of effective protective measures, duration of the events (responding after a sporadic incident varies greatly from an ongoing situation), the need for first respondents to care for themselves, minimizing first-responder fatalities and casualties, morale aspects of staff, safety of personnel family members, threat of role abandonment.

All this has identified the need for an integrated preparedness program.

So the aim of the article is the attempt of improve the hospital preparedness and response to mass causalities, by adapting emergency-management concepts and enhancing the resilience. A realistic approach to good emergency management involves awareness of the limitations in preparing for a scope of unknown variables.

The introduction of these principles contributes to greater awareness of

unexamined elements when preparing a response plan. Giving a general and systemic approach within the emergency health care system in Israel. preparedness toward chemical and biological casualties are not part of the daily routine of a civilian general hospital: its complexity requires a major management effort.

In order to achieve results, appointment of a senior executive is of paramount importance. And indeed, at Tel Aviv Sourasky Medical Center, a top executive officer (deputy CEO) was appointed to coordinate and expedite the process, He possesed high decision making responsibilities, wide spectrum vision, vertical and horizontal negotiation capabilities, and personal commitment to success.

The CEO personally related with the staff and the situation, he was constantly available and present in the field.

A team work group started a dynamic process of evaluation and meetings with the hospital management including support unit leaders and the central emergency.

A variety of external elements and issues was addressed the collaboration with key organisms in the environment of the hospital like the authorities of public health, the Israeli Defense Forces, Units of command, and military hospital support units, city administration, local polices and civil volunteer organizations.

As well was reinforced the dialogue between management and staff, overcoming problems, mitigating the organization conflicts, the main objective focused on evolving from a top-down process to and interactive orientation, that would encourage effective problem solving, addressing future upcoming


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hazard through an organization wide communication network (something that can be called as self-organization).

The use of experts in human behavior under extreme stress in the emergency team work groups as well as their participation in executive management meetings fostered greater awareness and readiness to deal with issues of personnel safety, impasses relating to personal hazards, psychological resilience, and to attempt to improve coping skills to staff in all echelons.

Consultation got underway through individual assessment meetings with the hospital management personnel including the support unit leaders and the central emergency headquarters members. Use of available communication technology, information flow, discrepancies between needs and resources were deliberated.

During individual meeting with chief executives and emergency team leaders, goals, needs, gaps, difficulties, and expectations were assessed. This served also as a catalyst for accelerating preparedness action on their part.

Quarantelli makes the distinction between disaster planning and disaster management, viewing planning as strategy and management as tactics.

Principles of good planning include a continuing planning process rather than an introduction of an end product, adoption of a multihazard view that focuses on coordination of emergent resources rather than imposing command and control, emphasizes an inter- and intraorganizational integration, anticipates likely problems and possible solutions, and relates to all phases of planning process (mitigation, preparedness, response, and

recovery).

Quarantelli asserts that although it is impossible to anticipate the specific tactics to be used in an actual crisis (because they will be tailored to the actual emergency that develops), disaster preparedness should highlight tactical considerations involved in efficient and effective disaster management [9]

Adapting Quarantelli’s approach to disaster mitigation to the micro-infrastructure of the Tel Aviv Sourasky Medical Center, was attempted by the hospital to foster an interactive management process that would deal with the various contingencies stemming from the new hazard of chemical and biological hazards.

The 10 criteria for good disaster management were defined as follows[9]:

1. Recognize correctly the difference between agent and response generated needs and demands. 2. Carry out generic functions in an adequate way. 3. Mobilize personnel and resources effectively. 4. Involve proper task delegation and division of labor. 5. Allow adequate processing of information. 6. Allow the proper exercise of decision-making. 7. Focus on development of overall coordination. 8. Blend emergent aspects with established ones. 9. Provide the mass communication system with appropriate information. 10. Have a well-functioning Emergency Operations Center The previous criteria for disaster


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management used not only for managing the emergency in hospital can be seen as the way, how the kibbutzim are settled. As long as the strategy sharing a common goal enhance the communication during a unexpected event.

On the other hand the secondary element (awareness to uncertainty behalf Quarantelli about the emergency preparedness) was used by the Tel Aviv Sourasky Medical Center including two faces for assessing, the consultation and training, as important elements for (a) increasing awareness of hospital management to psychological needs of staff under hazardous conditions and (b) training the staff team leaders to use leadership in order to enhance resilience, respond to personal needs, and promote cohesiveness and coping skills.

The managing consulting intended to focuses in its actions in the communication, as was explained previously using the shoal analogical example, the activity of a holistic network toward resilience can be sustainable as long as the communication is kept allowing the connectivity in our complex network in the emergency health care systems toward the capacity to absorb shocks.

How it can be achieved?, The experience of this hospital said that first is important to establish clear communication channels, harnessing the existing communication technologies we can exchange easily the information of the emergent performance of our organization; determining the information periodically during the emergency situation can anticipate the action over a fail in real time; building an alliance and establishing trust between management and staff on shared goals through public sharing of information

using feedback channels; setting up protective centers for the most vulnerable population; performing simulations and drills involved team leaders, emergency headquarters members, hospital executive management, and all external agencies; reevaluating placement of first responders involved assessment of previous experience; focusing in the first responding teams, to enable quick resolution in specific issues, using adaptive and flexible protocols; use of techniques for defusing the relieving the stress and the tension of team members; and establishing horizontal, and vertical communication channels rather than the traditional hierarchic ones, providing support and flexibility for emergency teams through constant adaptation for changing situations, dealing with personnel overload.

Staff training program, Is well know that performance under extreme psychological stress varies among individuals and organizations, this is a common feature of the holistic and organic systems. The resilience in terms of hardiness is a personality quality manifested in a positive approach of the stress of certain situation, characterized by three dimensions, control, commitment, and challenge. There are other factors are known to improve performance under stress, training, social support, various stress-coping techniques, self-esteem, trust in leadership, and fulfillment of basic needs. Considering the anticipated situation of exposure to unfamiliar danger, extreme stress, and only partially experienced civilian medical staff, the role of team leaders became crucial in promoting coping behavior and enhancing resilience of their team members.


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Empowering leaders and expanding their responsibility through establishing direct dialogue with management. In this way the training program can be settled in the assumption that we have to considering the team members are expected to work under extreme pressure, hazardous conditions, and great grade of uncertainty, second, the emergency team is going to be expected to react and perform well when team leaders provide appropriate guidance, and are familiar with the use of coping skills under stress. This focus can be seen as the way how each unit (fish) behave in the shoal when a risk is ahead in the ocean, or the way as the kibbutzim manage the hazard during a terrorist incursion keeping its functionality. The Tel Aviv Sourasky Medical Center thus designed and implemented hospital-wide training sessions for effective emergency team leadership of all disciplines. Instruction was modular and adapted to each professional group (dynamic-shoal). In the specific case of Biological and Chemical hazard focal teams were: triage, decontamination, mental health providers, hospital management departments, childcare facilities employees, and teams identified for high-risk of burnout, exhaustion, or extreme stress. An assessment period preceded each session. Team leaders in a dynamic leadership (a senior physician, a head nurse, and an administrator) were encouraged to bring up issues of concern; verbalize conflicts; assess duties; examine discrepancies; define special needs of their teams; and establish communications

channels with other relevant team leaders (neighbor fish), central emergency headquarters members, and hospital management. The role of team leaders was redefined to include caring for well-being of their staff, serving as role models for team members, and attending to both operational tasks and human needs while fostering group cohesion. A teaching session aimed at stress inoculation included information about the sources of stress, physical, emotional, behavioral and cognitive reactions, coping methods, and expectations. Participants were taught principles of emotional first aid, leadership skills in emergency, identifying and responding to normal stress reactions, maintaining long-term team performance, the importance of efficacy and seeking professional aid on the premises. As a conclusion of this evaluation of the specific case of the Tel Aviv Sourasky Medical Center we can conclude that the Implementation of an effective preparedness program is a dynamic, ongoing process a deep and intensive assessment of emerging needs, with a continuous improvement of communication, collaboration, coordination, intensified training of all team leaders, and an integrated view by all participants: inter and intra agencies related. This developmental process leans heavily on continuous sustenance. Facing the future and the uncertainty, can lead to establish the resilience engineering as long as we set a dynamic system that can respond to regular and irregular threats, and keep its robustness being flexible, on the other hand, the ability that is being developed in the Tel Aviv


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Sourasky Medical Center show us how this system approach the resilience whenever it intends to anticipate disruptions, pressures (Chemical and biological hazards). By last the Israeli thinking facing the uncertainty can be seen as a ability during its history to learn from the experience in catastrophic situations, which has been widely unfortunate and possibly at the same time fortunately. References. [1] Israel - CIA - The World Factbook Available [web site] https://www.cia.gov/library/publications/the-world-factbook/geos/is.html Accessed January 5, 2013. [2] Ministry of Health Available [web site] http://www.health.gov.il/English/About/Pages/default.aspx, Accessed January 5, 2013. [3] Erik Hollnagel, From protection to resilience: Changing views on how to achieve safety, Ecole des Mines de Paris, CRC, Sophia Antipolis, France. [4] Hollnagel, E., Woods, D. D. & Leveson, N. (2006) (Eds.). Resilience engineering: Concepts and precepts. Aldershot, UK: Ahsgate. [5] Assessment of health-system crisis preparedness World Health Organization 2012. [6] Rayman, Paula. The Kibbutz Community and Nation Building. Princeton University Press. [7] Israel Defense Forces. Available [web site] http://www.idf.il/daily_statistics/ english/1.gif. Accessed January 5 2013.

[8] Schreiber S, Yoeli N, Hospital preparedness for possible nonconventional casualties: an Israeli experience, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler School of Medicine, The Internet Journal of Rescue and Disaster Medicine ISSN: 1531-2992 25 may 2004. [9] Quarantelli E. Ten criteria for evaluating the management of community disasters. Disasters 1997.

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The israeli experience with hospital preparedness to terrorism

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