CC BY
0the impact of the
covid-19 pandemic on quality of care in israeli hospitals
Summary
The study goal was to assess the impact of the COVID-19 pandemic on strategies used by Israeli hospitals to improve quality of care, patient safety, patient experience and clinicians' well-being. Leaders of public hospitals in Israel were asked to complete questionnaires regarding the impact of COVID-19 on quality. Fourteen of 29 public hospitals participated. Statistically significant differences were noted in the impact of COVID-19 on infection control and clinician well-being by hospital ownership, but no other differences were found, The COVID-19 pandemic had mixed impacts on most domains. Positive impacts were noted to some extent in patient safety and infection control, while waiting times for outpatients and clinicians' well-being were more likely to be negatively influenced. The most common topics which were advanced during the COVID-19 pandemic were infection control, performance in national quality indicators, reporting of adverse events and near-miss events and care of diabetes, patient and family support in the COVID-19 unit, care in the emergency department, care of labor and delivery, supplying information for patients and the development of online services and telemedicine.
Keywords: quality, patient experience, infection control, COVID-19, pandemic
Резюме
Влияние пандемии COVID-19 на качество помощи в израильских больницах
Цель исследования состояла в том, чтобы оценить влияние пандемии COVID-19 на стратегии, используемые израильскими больницами для улучшения качества обслуживания, безопасности пациентов, качества обслуживания пациентов и благополучия врачей. Руководителей государственных больниц в Израиле попросили заполнить анкеты о влиянии COVID-19 на качество. В нем приняли участие 14 из 29 государственных больниц. Были отмечены статистически значимые различия во влиянии CO-VID-19 на инфекционный контроль и благополучие врачей в зависимости от принадлежности больниц, но других различий обнаружено не было. Пандемия COVID-19 оказала неоднозначное воздействие на большинство областей. Положительные последствия были отмечены в некоторой степени в отношении безопасности пациентов и инфекционного контроля, в то время как время ожидания амбулаторных пациентов и самочувствие клиницистов, скорее всего, подверглись негативному влиянию. Наиболее распространенными темами, которые поднимались во время пандемии COVID-19, были инфекционный контроль, выполнение национальных показателей качества, отчетность о
CZU: [616.98:578.834.1]-036.21:614.21(569.4)
Dalia Dreiher
Free International University of Moldova, Supervisor at the Research and Development Division, Employee of Ministry of Education, Israel E-mail: dreiher@gmail.com
https://doi.org/10.52556/2587-3873.2022.2(93).01
нежелательных явлениях и критических ситуациях, а также лечение диабета, поддержка пациентов и их семей в отделении COVID-19, уход в отделение неотложной помощи, родовспоможение, предоставление информации пациентам и развитие онлайн-сервисов и телемедицины.
Ключевые слова: качество, опыт пациента, инфекционный контроль, coviD-19, пандемия
Rezumat
Impactul pandemiei de COVID-19 asupra calitatii ingri-jirii in spitalele israeliene
Scopul studiului a fost de a evalua impactul pandemiei de COVID-19 asupra strategiilor utilizate de spitalele israeliene pentru a imbunatati calitatea ingrijirii, siguranta pacientilor, experienta pacientului si bunastarea clinicienilor. Liderii spita-lelor publicedin Israelau fostrugatisa completezechestionare cu privire la impactul COVID-19 asupra calitatii. Au participat paisprezece din cele 29 de spitale publice. Au fost observate diferente semnificative din punct de vedere statistic al impac-tului COVID-19 asupra controlului infectiei si asupra bunastarii clinicianului in functie de afilierea spitalelor, dar nu au fost gasite alte diferente. Pandemia COVID-19 a avut impacturi mixte in majoritatea domeniilor. S-au observat intr-o oarecare masura impacturi pozitive in siguranta pacientilor si controlul infectiilor, in timp ce timpiideasteptarepentrupacientiiam-bulatori si bunastarea medicilor erau mai susceptibile de a fi influentate negativ. Cele mai frecvente subiecte care au fost avansate in timpul pandemiei de COVID-19 au fost controlul infectiilor, performanta in indicatorii nationali de calitate, raportarea evenimentelor adverse si a evenimentelor aproape de accident si ingrijirea diabetului zaharat, sprijinul pacientului si familiei in unitatea COVID-19, ingrijirea in departamen tul de urgenta, ingrijirea travaliului si a nasterii, furnizarea de informatii pentru pacienti si dezvoltarea serviciilor online si telemedicina.
Cuvinte-cheie: calitate, experienta pacientului, controlul infectiilor, COVID-19, pandemie
Introduction
This paper describes the impact of the cO-vID-19 pandemic on israeli hospitals' efforts to improve the quality of care, patient safety, and patient experience, based on a survey conducted by the author.
the coVID-19 pandemic was officially declared in March 2020, after a rapid vehement global spreading of the disease [4, 8]. the pandemic has caused
overwhelming effects on hospitals and healthcare facilities [3]. Some of these effects - the risk of being in the "frontline"fighting the disease, the high surge in workload burden - had compelling effects on healthcare workers [3, 5. 17].
The degree of investigation of the problem at present, the purpose of the research
The COVID-19 pandemic had a very strong influence on healthcare systems worldwide. Where people got used to certain standards of care, some compromises need to be done. Sabetkish & Rah-mani [14] lists several influences of the COVID-19 pandemic on the healthcare system. These include postponement of elective procedures and nonurgent medical care, increased use of telemedicine, decrease in outpatient visits and negative impact on training programs [14]. Additional aspects include limited access for hospital visitors and suspension of volunteer programs [10]. A drop in the number of emergency department visits was seen in many countries, including the US, United Kingdom, Italy, Thailand, Jordan and Israel [1, 18]. In a study of 1.3 million visits to the emergency department during 2018-2021, a 22% decrease in visits to the medical ED was noted, while visits to the surgical ED dropped by 19%. Thirty-days mortality following a visit to the medical ED increased by 8%, while for the surgical ED it increased by 18% [18]. Several reports regarding quality indicators in various countries reported decreased compliance with the measures. In the USA, the Centers for Medicare and Medicaid suspended the reporting of quality indicators, and data for the first six months of 2020 was announced to be excluded from the evaluation and payment programs of American hospitals [12]. In contrast, reporting to the National Quality Indicator Program in Israel continued as before. A report by Konson et al. [12] showed that while the caseload for many indicators decreased, performance rates in general hospitals were preserved and even increased. As in previous epidemics, a disproportionate burden on the poorest and most disadvantaged populations was noted in Jordan [1] and in Israel, leading to widening social inequalities. Obviously, the pandemic had a negative impact on the well-being of clinical staff. In a study of 600 frontline clinicians in Australia, concerns were raised regarding infecting family members, friends and colleagues with COVID-19, the proper use of protective equipment, and its effect on patient care, concerned regarding the quality of care provided, and various personal concerns [10]. In a study of Israeli healthcare workers, the negative impact of quarantine was noted mainly among nurses, with feelings of shame related to the need for quarantine especially noted [9].
The goal of the present study, conducted as a part of a broader study of strategies used to improve quality in Israeli hospitals, focuses on the question whether there could be some opportunities to learn from the experience gathered in this harsh period in order to further advance healthcare systems. It could be hypothesized that some of the "energy" of leaders of the healthcare system in these countries was focused on coping with COVID-19 and that less focus was available for continuing routine quality monitoring activities. In addition, the performance in some indicators (e.g., adherence to preventive measures) could be declining due to reduced compliance and lockdowns. The study's hypothesis was that the COVID-19 pandemic will have mainly negative impacts on hospital performance, but some positive trends will also be found.
Methods and materials applied
The goal of the present study was to examine the impact of COVID-19 on quality and patient safety, patient experience and clinicians'well-being. Senior leaders (Director Generals, Deputy Director Generals, Nursing Directors and Administrative Directors) in Israeli general public hospitals were interviewed regarding initiatives related to quality, patient safety, patient experience and clinicians' well-being, as well as the positive and negative impacts of the pandemic. Questionnaires were filled by the respondent and sent by mail. Questionnaires included questions about topic related to clinical quality and patient experience that were advanced during the pandemic. Similar questions were asked in each domain ("Did the COVID-19 pandemic had positive, negative, mixed, or no effect on this domain?"; "Which positive impacts did the COVID-19 pandemic had on this domain?"; "Which negative impacts did the COVID-19 pandemic had on this domain?" Data was cross-tabulated against the various domains of quality. The results are graphically described using pie chart. For the description of specific questions related to quality and patient safety, results were listed in a table or are quoted in the text.
In Israel, there are 329 hospitals. Of these, 43 are general hospitals. Of the 43 hospitals, there are 29 public hospitals. Of these, 18 representatives responded.
Results obtained and discussion
Most respondents (15, 83%) were CEO or deputy CEO, male (12, 67%), and in the age group of 41-50 years (11, 61%). The impact of COVID-19 on various domains is listed in Table 1.
Table 1
Positive, negative and mixed impact of COVID-19 on quality in Israeli hospitals
Domain Positive impact Mixed impact Negative impact No Impact
Quality (n=17) 3 (18%) 11 (65%) 3 (18%) 0 (0%)
Patient safety 6 (33%) 7 (39%) 1 (5.6%) 4 (22%)
Infection control 8 (44%) 8 (44%) 1 (5.6%) 1 (5.6%)
Patient experience 5 (28%) 8 (44%) 5 (28%) 0 (0%)
Waiting times for outpatients 1 (5.6%) 6 (33%) 6 (33%) 5 (28%)
Clinicians' well-being 0 (0%) 10 (56%) 8 (44%) 0 (0%)
Source: elaborated by the author based on a survey of Israeli public hospitals
The COVID-19 pandemic had mixed impacts on most domains. Positive impacts were noted to some extent in patient safety and infection control, while waiting times for outpatients and clinician's well-being were more likely to be negatively influenced.
We examined the association between hospital attributes, including ownership (government or Clalit healthcare provider organization), hospital size,
location within Israel, and accreditation status on hospital's responses (Table 2). The only statistically significant difference found was that in hospitals owned by the government there was a higher percentage of responders indicating positive impact of the pandemic on infection control, while also a higher percentage indication negative impact on clinician well-being (Table 2).
Table 2
The association between impact of COVID-19 on quality in Israeli hospitals and hospital attributes
Domain Hospital size Hospital ownership Location (periphery vs. center) Accreditation status
Quality 0.808 0.768 0.742 0.410
Patient safety 0.969 0.374 0.142 0.854
Infection control 0.258 0.009* 0.488 0.862
Patient experience 0.603 0.207 0.538 1.000
Waiting times for outpatients 0.512 0.963 0.854 0.199
Clinicians' well-being 0.386 <0.001** 0.180 0.680
Data presented are p-values for the cross-tabulation of hospital attributes and impact of COVID-19 on the various domains. * In government owned hospitals. 86% indicated positive impact while none indicated negative impact; in Clalit-owned hospitals, 18% indicated positive impact while 9% indicated negative impact
** In government owned hospitals, none indicated positive impact while 100% indicated negative impact; in Clalit-owned hospitals, none indicated positive impact while 9% indicated negative impact and most (91%) indicated mixed impact.
Source: elaborated by the author based on a survey of Israeli public hospitals
In terms of clinical quality, the most commonly cited positive impact was the use of telemedicine and digital services, while the most commonly cited negative impact was less focus from management / resource allocation. The most common topics related to quality which were advanced during the COVID-19 pandemic were infection control, performance in national quality indicators, reporting of adverse events
and near-miss events and care of diabetes (Figure 1).
The most commonly cited positive impacts of COVID-19 on patient safety were increased awareness to infection prevention and safety, better monitoring equipment and infrastructure and better strategies for patient safety. The most commonly cited negative impact was resource allocation and attention by leaders.
Figure 1. Quality topics advanced during the COVID-19pandemic in Israeli hospitals Source: elaborated by the author on a survey of Israeli public hospitals
The coviD-19 had several positive impacts on infection prevention, such as improved infrastructure and increased adherence to hand hygiene and universal precautions. the most commonly cited negative impacts were resource allocation to non-covid issues and difficulties in adhering to protocols.
several topics were noted as positive impacts on patient experience, including improved communication channels with patients and families, making the patient stay more pleasant, and
increased telemedicine capabilities and digital services. The most commonly cited negative impacts were the need to limit the number of visitors and resource allocation by management and staff. the most common topics advanced during the coviD-19 pandemic were patient and family support in the covID-19 unit, care in the emergency department, care of labor and delivery, suppling information for patients and the development of online services and tele-medicine (figure 2).
Figure 2. Patient experience topics promoted during the COVID-19 pandemic in Israeli hospitals Source: elaborated by the author on a survey of Israeli public hospitals
The COVID-19 pandemic had both positive impacts on waiting times for outpatients, such as the use of telemedicine, and increased availability for those willing to come, while the most commonly cited negative impact was longer waiting times due to decreased availability of outpatient services during quarantine.
Finally, the pandemic had mainly negative impacts on clinician well-being (increased burnout and workload, social distancing from patients, uncertainty, and fear of infection). The most commonly cited positive impact was gratitude to staff from management and the public.
The main findings in this study show mixed impacts on quality of care, infection control and patient experience, with a mainly negative impact on burnout and clinician well-being. This is in line with several previous studies, both from Israel and abroad. Sabetkish & Rahmani [14] also noted negative influence of the COVID-19 pandemic on waiting times for elective procedures and non-urgent medical care, and a decrease in outpatient visits. Konson et al. [12] showed that performance rates in quality indicators in general hospitals were preserved and even improved. In the National Program for Quality of care in the Community, a decrease in performance related to preventive care was noted. For example, annual HbA1c testing among persons with diabetes decreased from 91% in 2019 to 88% in 2020. In addition, 4.5% fewer mammograms were performed in 2020 compared with 2019 [13]. Several studies reported negative impacts of the COVID-19 pandemic on clinician well-being [2, 6, 9, 11, 15, 16]. In a study of Israeli healthcare workers, the negative impact of quarantine was noted mainly among nurses, with feelings of shame related to the need for quarantine especially noted [9]. Similarly, high levels of burnout were noted in ICU nurses following the COVID-19 pandemic [11]. In a study of hospital residents [15], common problems included depression and anxiety (47%), post-traumatic symptoms, burnout, and substance abuse such as alcohol and cannabis (11%). Israeli emergency physicians reported high burnout levels, which increased during the pandemic. Specific burnout factors were fear of infecting family members, lack of care centers for the physician's children, increased workload, and insufficient logistic support [16]. In a survey of healthcare workers, concerns for family members and apprehension were noted [2]. The way the crisis was managed was negatively precepted. A regression model showed that low self-assessment of coping with the crisis, deep concerns at the organizational level, negative perceptions of crisis management, and providing care for COVID-19 patients were predictors of burn-
out [2]. However, a small study among physicians in northern Israel noted a decrease in burnout levels [6] during the pandemic.
This study is the first study to deal with the impact of the COVID-19 pandemic on quality of care in its broadest sense, in Israeli hospitals, from the viewpoint of leaders. Furthermore, is deals with various domains of quality in a comprehensive way, not focusing solely on patient safety, infection control or clinician well-being. Its main limitations are the small sample size (18 respondents) and the selective nature of hospitals included (for example, public hospitals not owned by the government or Clalit chose not to participate). A more extensive study is needed with the representation of all Israeli public hospitals.
Conclusions
We can conclude that during the COVID-19 pandemic, hospital leaders reported generally mixed effects of the pandemic, with some positive impacts noted, while many negative impacts were similarly reported. The chief domains positively influenced by the pandemic include infection control and patient safety, while decreased availability of outpatient services and worse clinician well-being were noted. Among the specific aspects mentions, positive impacts included increased awareness to the hand hygiene and the proper use of protective equipment, more stress on patient safety, and the increased use of telemedicine. Among the negative impacts listed, the main ones included resource allocation and managerial focus on COVID-19, shifting attention away from routine quality issues, limitations on visitors, and the impact of burnout and increased workload on staff's well-being.
Similar to other countries, the COVID-19 pandemic caused decreased availability of services, increased use of telemedicine, limited access for hospital visitors and a negative impact on clinicians' well-being. Given that a previous study [7] found that the monitoring of clinicians' well-being is an especially neglected aspect of quality in Israel, the increased burnout and workload reported by hospital leaders is especially concerning.
References
1. AL-QUDAH, M., AL-SHAIKH, A., HADDAD, H., ALOLAYY-AN, M., et al. Impact of COVID-19 exclusive allocation strategy on quality of healthcare: A study from Jordan, 2020. Health Secur 2022 Apr 29. Doi: 10.1089/hs.2021.0146. ISSN 2326-5108 (IF: 1.810). https://www.liebertpub.com/doi/epdf/ 10.1089/ hs.2021.0146
2. BASHKIN, O., DAVIDOVITCH, N., ASNA, N., SCHWARTZ,
D., DOPELT, K. The organizational atmosphere in Israeli hospital during COVID-19: Concerns, perceptions, and burnout. Int J Environ Res Public Health 2021; 18:5544. (IF: 3.364). https://www.mdpi.com/1660-4601/18/11/5544
3. BENNETT, P., NOBLE, S., JOHNSTON, S., JONES, D., et al. COVID-19 confessions : a qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open 10:e043949. Doi: 10.1136/bmjo-pen-2020-043949. ISSN 2044-6055 (IF: 2.692). https:// www.ncbi.nlm.nih.gov/ pmc/articles/PMC7745452/
4. CLARK, E., AKAMINE, C., SHANDERA, W.X. Common viral respiratory infections. In: Papadakis MA, McPhee SJ, Rabow MW, McQuaid KR (Eds.) Current Medical Diag nosis and Treatment 2022. ISBN 978-1264269389. https://accessmedici ne.mhmedical.com/content. aspx?bookid= 3081§ion id=258978949
5. COLOMB-COTINAT, M., POUJOL, I., MONLUC, S., VAUX, S., et al. Burden of COVID-19 on workers in hospital settings: The French situation during the first wave of the pandemic. Infect Dis Now 2021;51:560-3. ISSN 2666-9927. https://www.ncbi.nlm.nih.gov/pmc/arti-cles/PMC8262402/
6. DIKMAN, N., KHAMISY-FARAH, R., FARAH, R., ESSA-HADAD, J., LIPAVSKI, N., BEN SHLOMO, I. The effect of COVID-19 pandemic on burnout among physicians in northern Israel hospitals (letter). IMAJ 2022; 24: 342. (IF: 0.978). https://ima-files. s3.amazonaws.com/377842_1233c7de-bc95-4e18-8839-f83887da0369.pdf
7. DREIHER, D. Strategies used by Israeli hospitals to promote quality. Economica 2022 (under review). ISSN 1468-0335 (IF: 2.397).
8. GE, H., WANG, X., YUAN, X., XIAO, G., et al. The epidemiology and clinical information about COVID-19. Eur J Clin Microbiol Infect Dis. 2020;39:1011 -9. ISSN 0934-9723 (IF: 3.267). https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC7154215/
9. HAGANI, N., EILON, Y., ZEEVI, S., VAKNIN, L., et al. The psychosocial impact of quarantine due to exposure to COVID-19 among healthcare workers in Israel. Health Prom Int 2022, 1-10 ISSN 0957-4824 (IF: 2.483). https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC8905960/
10. HOLTON, S., WYNTER, K., TRUEMAN, M., BRUCE, S., et al. Immediate impact of the COVID-19 pandemic on the work and personal lives of Australian hospital clinical staff. Australian Health Review, 2021, 45, 656-666. ISSN 0156-5788. (IF: 1.990). https://www.publish.csiro. au/ah/pdf/AH21014 (visited 30.05.22)
11. KAGAN, I., LANCMAN, N. WEISBORD, I. Experiences and psychosocial predictors of professional function among intensive care nurses under the shadow of COVID-19: A mixed-methods study. J Nurs Sch 2022;
1-12. (IF: 1.768). https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC9349997/
12. KONSON, A., KUNIAVSKY, M., BRONSHTEIN, O., GOLDSCHMIDT, N., et al. Quality of care indicator performance was minimally changed in 2020 despite the COVID-19 pandemic. Isr J Health Policy Res 2022; 11:9. https://doi.org/10.1186/s13584-022-00516-x ISSN 2045-4015 (IF: 2.385).
13. ROSE, A., EIN MOR, E., KRIEGER, M., BEN-YEHUDA, A., et al. Israeli COVID lockdowns mildly reduced overall use of preventive health services, but exacerbated some disparities. Int J Qual Health Care 2022; 34:1-6. (IF: 2.038). https://academic.oup.com/intqhc/arti-cle/34/3/mzac071/6692292
14. SABETKISH, N., RAHMANIEALTH, A. The overall impact of COVID-19 on healthcare during the pandemic: A multidisciplinary point of view. Health Sci Rep. 2021;4:e386. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC8485600/
15. SAR-EL, R., ANGEL, Y., FIRE, G., AVNI, A., TENE, O. The price of internship through COVID-19: 1st year physicians report substantial mental health symptoms during the pandemic. Gen Hosp Psychiatr 2022; 78:111-16. (IF: 3.220). https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC9388293/
16. SHOPEN, N., SCHNEIDER, A. AVIV MORDECHAI, R, KATZ SHALHAV, M., et al. Emergency medicine physician burnout before and during the COVID-19 pandemic. Isr J Health Pol Res 2022; 11:30. (IF: 1.670). https:// ijhpr.biomedcentral.com/articles/10.1186/s13584-022-00539-4
17. SPOORTHY, M.S., PRATAPA, S.K., MAHANT, S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic- a review. Asian J Psychiatr. 2020;51:102119. Doi: 10.1016/j.ajp.2020.102119. ISSN 1876-2018 (IF: 3.543). https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC7175897/
18. WOLF SAGY, Y., CICUREL, A., BATTAT, E., SALIBA, W., et al. The impact of COVID-19 pandemic on emergency department visits and associated mortality during 14 months of the pandemic in Israel. Int Emerg Med 2022; https://doi.org/10.1007/s11739-022-02991-1. ISSN 1828-0447 (IF: 3.397). https://www.ncbi.nlm.nih. gov/pmc/articles/PMC9108137/
Dalia Dreiher
Free International University of Moldova, Supervisor at the Research and Development Division, Employee of Ministry of Education, Israel
e-mail: dreiher@gmail.com Acceptat spre publicare 16.11.2022
