Understanding Hospital Employment

Employment in Israeli Hospitals is dependent on the availability of a 'Teken'.

What is a Teken?

A תֶּקֶן refers to an officially approved, funded position within a department or organization.

The plural of תֶּקֶן (teken) in Hebrew is תְּקָנִים (tkanim) - pronunced: tka-NEEM.

In simple terms: A teken is the ability to employ a doctor

This includes doctors at all stages of training - whether a resident, a junior specialist, or a senior physician.

At its core, the number of available tkanim is based on the number of patients.

The required ratio between doctors and patients in hospitals is defined by the Goldberg staffing standard.

How is the Doctor to Patient Ratio Set?

The Goldberg staffing standard (תקינת גולדברג) is the main historical formula used to determine the minimum number of physicians required in Israeli hospitals.

It originated from the 1976 physicians’ labor agreement, and its core principle was to calculate staffing largely according to the number of hospital beds in a department.

The original formula established a baseline of roughly one physician for every five hospital beds in inpatient wards.

This was intended to create a standardized way to determine how many doctors a hospital department should have.

Here are some examples of the set minimum standards:

1. Inpatient departments

For hospital wards:

• 1 department head

• 1 physician per 5 beds up to 30 beds

• 1 physician per 8 beds beyond 30 beds

This formula applies to general inpatient departments such as internal medicine or surgery.

2. Anesthesia

Staffing includes:

• 1 department head

• 1 anesthesiologist per 30 surgical beds

• 1 anesthesiologist per 300 hospital beds

• Additional anesthesiologists for certain specialized departments such as neurosurgery or cardiothoracic surgery.

3. Outpatient clinics and institutes

For clinics that do not have inpatient beds:

• 1 physician position for every 2,500 patient visits per year

4. Emergency departments

Emergency room staffing includes:

• 1 department head

• In hospitals with more than 400 beds, also 1 deputy director

• 1 physician per 3,250 emergency visits (calculated using 30% of the total annual visits).

5. Intensive care units (ICU)

ICU staffing includes:

• 1 department head

• 1 physician for every 2–4 ICU beds, depending on the type and size of the unit.

Although the model created a standardized way to calculate hospital staffing, it has several major limitations:

• It is based primarily on bed numbers, not real clinical workload.

• It was designed in the 1970s, before many modern technologies and subspecialties existed.

• It does not account for population aging, increased documentation, or complex procedures.

Because of these limitations, many health policy experts argue that the Goldberg system no longer reflects the real staffing needs of modern hospitals. (To be discussed further in a future blog)

How Many Staffing Positions Are Available?

The answer is not straightforward. The number of Tkanim available will depend on the type of hospital (government vs public vs private) and on each hospitals leadership - namely, how they chose to delegate funding.

Government hospitals

For example, Sheba Medical Center, Wolfson Medical Center, and Barzilai Medical Center.

In government hospitals, physician positions (tkanim) are allocated by the Civil Service Commission. In practical terms, the government assigns funding for a defined number of doctor posts within the hospital. This funding is earmarked specifically for physician staffing and cannot be diverted to other purposes such as renovations, equipment purchases, or other operational expenses. There is good oversight.

These tkanim are generally not designated specifically for residents and specialists. Instead, they represent a total pool of physician positions. Hospital leadership then decides how to distribute those positions within departments - for example, how many will be filled by residents and how many by specialists.

Having said that, there are some resident specific Tkanim which were introduced as part of the Barbash Agreement (1997) - in response to heavy workloads in hospitals, a one-off policy added 360 funded residency positions. These positions are allocated based on department size and occupancy. For example, an internal medicine department with more than 30 beds and over 80% occupancy would receive funding for three additional resident positions.

Tkanim can become available if a doctor retires or leaves the hospital.

Hospitals belonging to Clalit Health Services

For example, Meir Medical Center, Kaplan Medical Center, and Soroka Medical Center.

Clalit is the oldest and largest health fund (HMO) in Israel, and it therefore owns and operates the largest number of hospitals in the country.

In Clalit hospitals, the government does not directly control the number of tkanim. However, hospitals must still comply with the minimum Goldberg staffing standards.

Hospital directors can decide that a department needs additional physician positions, but any increase in staffing must be approved by Clalit management - who will be responsible for funding the teken.

Clalit also has several ways of creating additional positions. One example is a Kupah-funded teken, where the HMO finances a residency position in a hospital. In return, the resident commits to working for the Kupah in the community after completing their training. This arrangement is often structured as an עתודה (atuda) agreement, which typically requires the doctor to work for the health fund for several years following residency.

Public hospitals That Are Not Government-owned

For example Laniado Medical Center, Hadassah Medical Center, and Shaare Zedek Medical Center.

Hospitals in this category rely largely on the CAP system, which determines how they are paid for hospital activity. Under this system, each health fund agrees on an annual spending limit with each hospital. Up to that limit, the hospital is paid the full rate for services such as admissions and procedures. Beyond it, payment drops significantly.

Because of this, additional activity generates much less income, which can make it harder for hospitals to justify expanding services or hiring more doctors, ultimately limiting their ability to create new physician positions (תְּקָנִים).

It's worth noting that oversight is much weaker in hospitals owned by health funds or other organizations, and so even if additional funding is transferred to the hospital, there is no guarantee that it will actually be used to create new tkanim.

Health Corporations Increase Financial Flexibility

In order to increase financial flexibility, most (if not all) Israeli public hospitals also operate aתַּאֲגִיד בְּרִיאוּת (health corporation). In some hospitals the corporation may be called the “Research and Infrastructure Development Fund,” but it functions in essentially the same way.

A health corporation is a separate legal entity that operates alongside the hospital. It is typically structured as a registered non-profit association and managed by hospital leadership. Its purpose is to provide hospitals with administrative and financial flexibility in areas where government regulation is restrictive. The corporation can generate income from activities such as research, additional medical services, or collaborations, and these funds can then be reinvested in hospital activity.

Because corporations can manage funds outside the regular government budget, hospitals sometimes use them to support additional clinical work, pay doctors for extra shifts, or fund positions that are not part of the official state staffing allocation. For example, residency positions funded by a kupah/HMO are often administered through the hospital corporation rather than through the civil service payroll.

In practice, this means that some doctors working in a hospital may be employed through the ta’agid (corporation) rather than directly through the government system. While this flexibility helps hospitals cope with staffing pressures, it can also make the overall structure of hospital staffing more complex and less transparent.

Although these hospitals may have some flexibility to create additional tkanim, doing so is costly. A single physician position typically costs around 300,000–400,000 NIS per year, including salary and associated employment costs.

For this reason, the creation of new tkanim ultimately depends on whether the hospital has the available funding and whether its leadership chooses to allocate those resources toward additional staff.

Important Terminology

תֶּקֶן מֻרְחָב

Pronunciation: teken murchav

Meaning: Expanded position

A תֶּקֶן מֻרְחָב generally refers to a position that extends beyond a standard teken, often through additional funding or responsibilities.

Depending on the institution, this may include:

• funding from multiple sources

• a role combining clinical work with research or teaching

• a newly created or expanded position

The term is not always used identically across institutions, so it is reasonable to ask for clarification when discussing a job offer.

תֶּקֶן קֶרֶן מְחָקָרִים

Pronunciation: teken keren mechkarim

Meaning: A research position - physician post funded through external sources rather than the official state budget.

These positions are typically supported through a תַּאֲגִיד בְּרִיאוּת (ta’agid briut, health corporation) operating within a government hospital, as mentioned above. Physicians employed through research fund positions are not appointed under the State Service (Appointments) Law, and therefore they are not considered part of the formal government staffing allocation (תְּקָנִים רשמיים). Instead, they are employed in addition to the official staffing quota and may work clinically within hospital departments much like other physicians.

The significance of research tekens is that they allow hospitals to expand their workforce beyond the number of state-funded positions, helping departments manage workload or maintain services despite limited official staffing. Because these posts are funded externally and are not part of the formal staffing structure, they are generally not counted when calculating official physician positions or when determining the need for additional state-funded tekens.

Summary:

Understanding the context and structure behind how a staffing position (teken) is created is essential when approaching employment in an Israeli hospital.

Tkanim are a central topic in discussions about the healthcare system, particularly in relation to staffing shortages and the demanding 26-hour shifts that residents often work. Many physicians argue that these pressures could be alleviated by increasing funding to create more staffing positions.

In the next blog, we’ll explore this issue in more depth and look at the debate around expanding tkanim in Israel’s healthcare system.