The story of the Israeli-Syrian holding battles in the 1973 Yom Kippur War shows that even in the heat of a crisis you can adapt to changing conditions on the ground. What can the healthcare system learn from the Golan Heights’ small-team battles?
The greater the strain the medical system suffers under the COVID-19 pandemic, the clearer it becomes that for the Israeli healthcare system this is a seminal event on the scale of a war. Will it shape a new reality?
A senior administrator at one of Israel’s hospitals wrote me:
“The healthcare system’s normal operational model as a hierarchical system is not suitable to the current event. Small, separate, and rotating multidisciplinary teams is probably the most relevant model, but that is not how the system is designed and that is not how it normally trains its staff: teams are directed from above, separated into different sectors, with separate hours, rules and management…”
How can the healthcare system, which follows one hundred-year-old “Taylorist” management principles, deal better with the current crisis?
The Golan Heights, 1973
A few hours after Syrian forces broke Israel’s defense lines in the southern Golan Heights, Israel’s combined armored and paratrooper units were cut off from the home front and the senior command. The absence of a clear chain of command forced the fighting teams on the ground to operate completely independently.
The freedom to act according to the development of the theater liberated the forces to act flexibly and in direct lateral coordination, and improved their function on the ground. The previous acquaintance, trust, and communication between team commanders (junior officers and sergeants) enabled them to take initiative and disrupt the Syrian incursion plan [see here a study of the characteristics of those battles].
What can we learn from the Golan Heights holding battles that can help us confront the current medical crisis? Just like Israel’s standing army in the Yom Kippur War, the Israeli healthcare system entered the campaign unprepared, with a shortage of human resources and equipment, and operating under a centralized leadership that does not know how to delegate, coordinate between units, and maintain bilateral communication with working teams on the ground.
The healthcare system: centralization and separation instead of trust and freedom of action
The hospitals, both in terms of their management philosophy and their organizational structure, are structured around professional, sectorial medical wards that are as fortified as castles. Coordinated work between hospital ward physicians and nursing staff, imaging technicians and pharmacies, all treating the patient in a combined professional envelope – is still a distant and unattainable dream.
Even on the national system management level, the lateral and vertical coordination between government ministries and the Ministry of Health, the community’s health maintenance organizations (HMOs) and the hospitals, is partial and deficient, as is the coordination between working teams on the national, city and community levels: there is a preference for concentrating powers and handing down directives from above, instead of system-wide coordination and sharing out of a broader perspective.
One of the unfortunate outcomes of this defect is that the treatment of the rest of the public’s ills is being neglected, in favor of focusing on the coronavirus epidemic. Thus, according to a senior cardiologist who found himself almost unemployed: “The number of patients who die because they did not come in for urgent care out of fear of the coronavirus might be higher than the number of patients who die from the virus.” It turns out that when the entire system is divided into sectors, plugging up one hole creates an even more dangerous new one.
How to become a flexible and adaptive organization?
The story of the Golan Heights holding battles of the Yom Kippur War shows that even in the midst of a crisis one can adapt to a changing reality. Decentralizing the sectorial structure into integrated teams could enable them to take initiative and seize opportunities in real time, just like the moves that disrupted the Syrian incursion plan. I am not talking about the social distancing policy or the extent of testing, but about the level of coordination and maximization of crisis management potential.
The system cannot be changed all at once, but the enterprising spirit that was forced upon me and my comrades in the Golan Heights can be experimentally applied to the coronavirus crisis. The hospital management should serve as the “team of teams”, and operate out of a central coordination room (obeya) for the vertical integration and management of the campaign. At the same time, a cluster of combined and multidisciplinary autonomous operation teams should be set up, including experts in urgent medicine, intensive care, and anesthesia, along with nursing, imaging, logistical, pharmaceutical, and social work teams. Each combined team should be responsible for the patient’s treatment (value stream) and participate in developing standards (treatment protocol) and a work language between the teams and the “team of teams.”
The adaptive, “antifragile” organization is based on the combination of three organizational culture principles: a trusting relationship + professional excellence + integrity. The purpose of the senior medical administrations should be building patients’ and medical teams’ trust in the quality of public medicine in Israel. On the basis of that trust, the tasks and limits of the medical teams’ autonomy can be defined.
Crisis as opportunity for change
Compared to European countries, and certainly compared to the collapse of the U.S. healthcare system, the Israeli healthcare system has managed to cope with the coronavirus crisis admirably. The experience of the under-resourced medical teams currently functioning successfully in suboptimal conditions proves the advantage of enterprising and flexible work teams structured as a “network” over a hierarchical organization following detailed plans based on past experience.
It seems that it takes an unprecedented crisis to change a mindset. Even if the potency of an event may seem to cause the path to collapse, the experience of a crisis may reveal the existence of other paths.
It is impossible to make an advance plan for an unprecedented surprising event, but we can be prepared for such events becoming part of our reality. Building organizational and social resilience requires us not only to sustain crises but also to learn from them and come out stronger, for the unknown challenges we are likely to face in the future.
Boaz Tamir, ILE.
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