"Our pursuit of excellence is a journey, not a destination, and it is our responsibility to ensure that the best quality care is available to our patients." Dr. Aref Al Shehhi, Deputy Chief Executive Officer, SKMC

The Gulf Corporate Council (GCC) member states (UAE, Saudi Arabia, Qatar, Bahrain and Qatar) have been witnessing a tremendous increase in the demand for healthcare services and professionals especially at a time when markets across the globe are still recouping from the financial crisis. One influential reason for the skyrocketing healthcare jobs is that the industry is collectively upgrading its facilities and expertise to world-class standards (Saad, 2012). In fact, some standards actually surpass the levels of their European and American counterparts such as Saudi German Hospital-Dubai (Saad, 2012). A study done by Alpen Capital Investment (2014) state that "The GCC healthcare market is projected to grow at an annual rate of 12% to US$ 69.4 billion by 2018 from an estimated US$ 39.4 billion in 2013." Saudi Arabia is projected to remain the largest GCC market while Qatar and UAE are expected to be the fastest growing markets. (Alpen Capital Investment Banking, 2014)

Despite the growth in the healthcare market so are the costs associated with it. The main issues behind the increase in GCC healthcare costs are: the rise in sedentary and unhealthy lifestyle, shortage of medical professionals and the increase use of new and advanced technology. (Informa Exhibitions, Life Sciences, 2012) The GCC is recognized as one of the most obese regions in the world. Moreover, the link between obesity and type 2 diabetes is evident by the high percentage of adults suffering from both in the GCC. Studies suggest that obese patients spend 2 -3 times as much as the average patient on health care which puts a huge burden on health budgets than smokers. In the UAE for example chronic lifestyle disease and injuries cause almost 90% of all deaths (Informa Exhibitions, Life Sciences, 2012). Home-grown health specialist is another major problem in the GCC where health care institutions still depend on expatriate workforce, which account to 40-80% of the total workforce (Informa Exhibitions, Life Sciences, 2012). However, even though UAE physicians have better salaries compared to their neighboring countries, the medical profession is less appealing when one takes into consideration the number of working hours, the extensive training, the calls and liabilities etc. (Almazroui, 2014) According to HAAD, "Abu Dhabi alone would need additional 3,100 doctors by 2020". The rising health awareness, education and affluence of the population all contribute to increased use of new and advanced technologies which can increase the healthcare cost by 38-62% and is often not covered by insurance providers (Informa Exhibitions, Life Sciences, 2012).

With governments struggling to keep up with the unsustainable demand on healthcare, they are turning towards Public Private Partnerships (PPP) to "aid in the transfer of quality service to raise the level of healthcare provision across the region" said Julian Hawkins, Partner in charge for consulting services at Deloitte Middle East (Informa Exhibitions, Life Sciences, 2012). A successful PPP not just develops hard and soft infrastructure but also saves governments as much as 25% on healthcare costs. (Informa Exhibitions, Life Sciences, 2012) This is the case with the UAE where "the government is still footing 70% of the total health cost". (Informa Exhibitions, Life Sciences, 2012) But with Abu Dhabi being a driving force in the development of PPP, management partnerships with some of the major hospitals such as Varned, Cleveland Clinic John Hopkins and Bumrungrad has helped ease the burden.

According to the World Health Organization, "United Arab Emirates is the 27th in world healthcare systems" (UAE Government, 2014) Based on the principles laid out in the Abu Dhabi Economic Vision 2030 the UAE government has developed an advanced infrastructure for the existing and upcoming hospitals. "Currently there are 65 hospitals in the UAE, 15 of them federal institutions, and over 150 primary health-care centers and clinics, in addition to 11 school health centers, 10 centers for mothers and children and 110 special units for mothers and children in hospitals and primary health-care centers. This compared with 7 hospitals and 12 health centers when the Federation was established in 1971". (The UAE National Media Council May 2014).

Evidently, the health care system is changing rapidly. The UAE healthcare industry has shown an unprecedented growth which is expected to continue in the future due to increasing population, rising prevalence of lifestyle diseases and epidemic outbreaks like Corona virus and N1H1 flu. How does the continuous change and rising health care system impact the hospital's management and development to meet the needs and expectations of the public? To examine this question, we interviewed Ben Frank, Chief Executive Officer at Cleveland Clinic Foundation - Sheikh Khalifa Medical City Hospital, the flagship institution for the public health system in Abu Dhabi and the largest hospital and medical city in the UAE, consisting of 586-bed tertiary hospital and 14 outpatient specialty in addition to managing a 125-bed Behavioral Sciences Pavilion and an Urgent Care Centre. Sheikh Khalifa Medical City (SKMC) operates under the management of Cleveland Clinic, consistently named by U.S. News and World Report as one of the nation's best hospitals in its annual "America's Best Hospitals" survey. Prior to SKMC, Frank served as COO of East Jefferson General Hospital for four years and Chief Executive Officer of Central Arkansas Health System for three years. His experiences also include Chief Operating Officer with Piedmont Medical Center. He holds a bachelor's degree in Commerce and Business Administration from University of Alabama and a master's degree in Health Administration from Tulane University New Orleans, Louisiana. Overall, Ben has over 24 years of healthcare experience and joined SKMC in September 2012. The interview focuses on understanding the hospital structure, operations, technology and mentions the key issues impacting the patience experience in the future growth of the health care market with regards to the Emiratization policy and UAE vision 2030.

About the SEHA Health System and the Abu Dhabi Health Services Company PJSC (SEHA):
SEHA is health in Arabic. "The Abu Dhabi Health Services Company PJSC- whose marketing identity is SEHA - is an independent, public joint stock company created to develop the curative activities of the public healthcare system in Abu Dhabi. The company owns and operates all the public hospitals and clinics of the emirate of Abu Dhabi which together make up the SEHA Health System. SEHA is committed to providing high quality, cost effective healthcare in a socially responsible way on par with international standards measured through accessibility, affordability, choice and satisfaction. SEHA has partnered with internationally recognized hospital managers to achieve these goals. These include Johns Hopkins Medicine International, Cleveland Clinic Foundation, VAMED, Vienna Medical University and Bumrungrad International. SEHA owns and operates 12 hospitals with 2,644 beds, 62 ambulatory care, family care and urgent care centers and 2 blood banks. SEHA is one of the largest integrated healthcare providers in the Middle East, with 16,500 doctors, nurses, ancillary care and administrative personnel in its employ. " (SEHA Abu Dhabi Health Services, 2008)

Structure
SKMC is a SEHA health system facility and managed by Cleveland clinic. Explain this management structure and how it helps develop the next phase of SKMC.

SKMC is owned by SEHA, the Abu Dhabi Health Services Company, which oversees operations of all public hospitals in the emirate. In 2007, SKMC chose to have Cleveland Clinic manage the hospital under the agreement of key executives of SEHA and Cleveland Clinic. The Chief Medical Officer (CMO) has three Chief Deputy Medical Officers (CDMO) who each have certain divisions that report up through the deputy CMO's. We report to SEHA senior management. By the end of the management agreement in 2017, SKMC would choose one of three options: continue its agreement with Cleveland Clinic, have a modified agreement or could be independent as was the case with the Cornich hospital which was managed by John Hopkins Clinic and now is owned, operated and managed by SEHA. At this point in time it has not yet been determined which option SKMC would opt for. The value behind this agreement is to take what Cleveland clinic has done very well in the U.S and bring the expertise and programs to benefit the citizens of Abu Dhabi.

Physical changes: The current campus will remain intact. The expansion will happen at the back of the campus and is expected to finish in five years time by 2019. Abu Dhabi, SAHA and HAAD's (Health Authority Abu Dhabi) vision to expand healthcare services and be a part of the evolution of the new SKMC is to take the existing Cornich Hospital and move it to the new campus of SKMC to become integrated with the new hospital.

"The new Sheikh Khalifa Medical City will comprise three hospitals with a total of 838 beds, spread over 300,000 square meters. Such large medical cities and complexes, with billions of dollars of investments lined up, is expected to not only raise the supply of medical infrastructure but also raise the quality of healthcare services in the region". (Alpen Capital Investment Banking, April 2014)

How do you monitor the quality performance of each physician and ensure they get right access and understanding?
We go through annual reviews for physicians. Last year, SKMC published an outcomes book that shows outcomes such as medical training, actual quality figure and sometimes compare it to Cleveland clinic. When you are comparing to Cleveland clinic you are comparing to John Hopkins, the Mayo clinic and other top institutions in the world. We did this last year and expanded it. We have excellent outcomes that when Cleveland physicians came here they are truly amazed with the results and that where it shows great value in this relationship. They can learn from physicians here and export them back to the United States. So they constantly talk about their institutes and divisions on performance, patience satisfaction, and access and patience experience. But a level we haven't really gotten into yet is how to start evaluating physicians on key areas? ; a true personal patient experience where the inpatient and outpatient actually rate their physicians. Or how their peers rate their physicians? Then we look into productivity, outcome, adherence to quality, processes and compare that with Cleveland's model, called Annual Performance Review (APR) that really focus on key areas: quality, satisfaction and access.

In a multicultural environment such as the UAE, miscommunication between healthcare providers and patients is eminent if each party approaches diagnosis and treatment from a different perspective. According to the U.S department of health and Human Services "Cultural competency is one the main ingredients in closing the disparities gap in health care. It's the way patients and doctors can come together and talk about health concerns without cultural differences hindering the conversation, but enhancing it. Quite simply, health care services that are respectful of and responsive to the health beliefs, practices and cultural needs of diverse patients can help bring about positive health outcomes." (U.S department of Health and Human Services, 2013). SKMC has staff ranging from physicians to administrators from numerous values and difference backgrounds which gives SKMC the competitive edge over its U.S counterparts in part because the medical staff is relatively representative of the patient population at the hospital. This makes it less difficult for SKMC to achieve cultural competence. In the UAE, there are different views on family medicine issues when it comes to segregated waiting rooms, conservative lifestyle, and medical treatments for cancer, abortion etc where doctors and their patients may not arrive at the same conclusions given an identical set of symptoms, or even disagree on what behaviors are "healthy".

What are the benefits and drawbacks when Cleveland clinic experienced cultural changes when integration with SEHA happened?
Just because a program worked well in the United States may not necessarily mean it is going to work here. So we modified the patient experience program to be culturally adaptive and to be supported in different settings. Orientation programs and awareness campaigns help ease the differences but the drawback is the time it takes to understand cultures and make sure the program will be of great value and benefit where it's being implemented. Since taking control in 2007, considerable time was spent on patient experience and have actually taken programs from SKMC and brought those back to Cleveland Clinic. So it's a mutual relationship that it is not only Cleveland clinic bringing programs but what it can learn from a great partner and bring back to United States and around the world.

SKMC went through a lot of leadership change; inter health Canada, HAAD, Cleveland clinic. How has this impacted the progress and performance of the hospital for the past 14 years?

There has been a change in direction and a good progression since Cleveland Clinic has managed the hospital especially the considerable value brought by the relationship through learning how to better SEHA's expectations.

Operations and Technology in health care

SKMC just received its third accreditation last month by Joint Commission. How often are they reviewed and what other accreditation does SKMC have? When were they given?

There are many accreditations however the most important one is by Joint Commission International (JCI) which is reviewed every 3 years. It goes for 5 full days with 3 surveyors from the Joint Commission. They look at three specific areas; physicians, clinical and administrative. The lab is accredited and reviewed by the American Academy of Blood Bank every 2 years and HAAD is reviewed on a yearly basis. SKMC has held JCI accreditation since 2008, and again in 2011, and as mentioned in 2014. SKMC is also accredited as a Cycle IV Chest Pain Centre with Primary Angioplasty Intervention; and is accredited by the College of American Pathologists (CAP) for its Main Laboratory.

SKMC provides comprehensive healthcare services in all of the disciplines relevant to the needs and priorities of the community to attain the highest levels of patient satisfaction. What qualifications and standards must employees go through to reach the desired standards?

Employees know 6 months in advance prior to Joint Commissions' arrival. Communications are sent weekly through questionnaires and games, making it a fun learning experience. Employees should be practicing and adhering to these guidelines every single day so it should be built-in in how they take care of patients, both for HAAD and the blood banks survey. Since our mission is to provide compassionate, patient-centered care of the highest quality, Joint commission reaccreditation gives further proof that we are a distinguished provider of superior clinical outcomes for the people we serve.

What are the updates and training related costs that factors performance improvement?
Every year, SKMC budgets for education programs and career advancement with a staggering excess cost of AED 3 million for both nurses and physicians. The budgeting is discussed with SEHA and funded by SEHA. Part of the agreement is to also have corporate employees travel to the United States for training and they would provide fund for that as well. It may be to attend a "patient experience summit", a leadership academy or it may be focused on quality programs.

Can you tell us about healthcare excellence programs?
SKMC is using the European Quality Foundation Model (EQFM) and SEHA is pursuing the Dubai Quality Award (DQA). So the excellence is really focused on the quality process and whether we are maximizing our efficiency in the quality process that we are implementing throughout the institution.

What are the daily decision -making and team shaping opportunities to create a genuinely well performing and healing environment?
We as a leadership team meet almost daily. Senior management set objectives for daily, weekly, monthly and yearly strategies of the institution. Our goal is to really focus on the patient. "Patients' first" is what we truly believe in and everything we do has to focus around doing the right thing for the patient. Along with our medical staff, we continually look at ways into improving and perfecting patience care. Our feedback is done through monthly and daily rounding. Every month, 90 individuals from the leadership team, including myself and senior management, go to different areas of the hospital and talk to staff, patients and their families and ask what we can do better. Nurses and physicians interact daily, bringing constant feedback and try to solve what they can on the spot. Sometimes it can be complex due to a medical type of condition. But it all comes down to communication and how to continually communicate to ensure that patients and families know everything they should about their care. The monthly rounding has worked very well. Despite us being in the hospital every day, the monthly rounding gives the staff the opportunity to see and interact with us. We ask them "how is your day going?", "what can we provide you to help you do your job better?" If they say we need this piece of equipment and it is really expensive, we'll look into it but some things we problem solve immediately.

How do you invest in equipment and experienced leaders to provide world class healthcare and drive performance?
Our technology is very up to date. Just recently we were the first in the Gulf to implement the smart IV room which will be used to prepare Total Parenteral Nutrition (TPN) which administers the supply of all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a vein. TPN can be used at home for patients who are less mobile and have travel restrictions and therefore provides convenience and peace of mind. In some cases our equipment may be just a little behind technology in terms of Cleveland Clinic. It has to pilot new equipment before it hits the market. In some areas we are as advanced as Cleveland and in others our goal is to become as cutting edge as Cleveland.

What managing information system are you using? How does it benefit them?
SEHA has a very advanced IT system which is very patient focused too. We use a system called "CERNER" (a leading worldwide provider of health information systems and technologies) that's used across the entire SEHA system. The term "Malafi" which means my file/record in Arabic is an individual file that allows patients to access their own medical records electronically from any SEHA operated institution such as Mafraq, Tawam, Abu Dhabi Health Services, etc. This instant access encourages collaboration between departments and the wider Abu Dhabi medical community which enhances the patience care and efficiency without compromising on confidentiality.

Any research facilities? If not, is there in the future?
We do a significant amount of medical research but it is more on physicians doing studies and publishing papers rather than the clinical/lab type. We could be more into labs but that is a couple years out due to it being complex to initiate. You must have a hidden instigation review board that monitors clinical trials and protocols that CCAD might look into more than us. I am not aware if Tawam is doing further cancer research along with their partner John Hopkins who has a molecular type of study for that level of clinical trials.

According to Alpen Capital (2014), a leading investment Bank that provides solutions to corporate clients in GCC and Asia, one of the challenges of the GCC region is the insufficient number medical practitioners present within their countries. The region is reliant on foreign professionals for meeting the rising demand of health care. However, in the UAE, the reliance on foreign practitioners has declined due to the proactive measures of the UAE government in implementing the Emiratization policy in the healthcare market.

Emiratization

What percentage of Emiratis work at SKMC at the moment? What are the ratios of male to female?
We have a target which is 15% and right now we are exceeding that target with a 15.3% in Emirati workforce: Emirati Female is 73.7%, Emirati Male is 26.3%

Tell us about the Emiratization program and their contribution level at SKMC and SEHA.
We have a national HR director who is very proactive trying to bring more nationals into SKMC. Not only are we focused on our Emiratization of our workforce but also our medical training where we are developing UAE national physicians who will graduate and further support the SEHA system as a physicians in key areas. The numbers of UAE national qualified physicians are increasing drastically and the last graduating class was almost ¾ females. So we are seeing more females being interested in becoming a physician.

Do you have examples of training methods or programs to develop the skills of nationals?
Investing in Emirati doctors is of great importance. We provide them with appropriate education and training and with employment opportunities after graduation. At a management level, one of my goals is to mentor and provide guidance to my colleague who is Chief Deputy Executive Officer (Dr. Aref Al Shehhi) so he will eventually become a CEO (Leadership development and succession planning). The same goes for Foreign Deputy Operation Officers who are mentored by our National Chief Medical Officer. One of SEHA's major goals is to raise the level of resident physicians. SKMC worked closely with SEHA and the US-based Cleveland Clinic in 2013 to produce Emirati leaders of the future with the "Three month Observership program" in Cleveland Clinic, United States, empowers the national healthcare professionals to integrate innovation into daily clinical activities. The organizations partnered throughout the year to deliver the UAE Executive Fellowship Program, which had the purpose of advancing senior Emirati roles in the management of healthcare facilities in Abu Dhabi.

Future
According to HAAD, diabetes and obesity are recognized as being particularly prevalent in the UAE. The World Health Organization (WHO) statistics show that the UAE has the world's second highest rate of diabetes at around 19% overall and that this is higher amongst the National population. (Health Authority Abu Dhabi, 2012) In the UAE, chronic lifestyle disease and injuries cause almost 90% of all deaths (Informa Exhibitions, Life Sciences, 2012). Adult nationals were screened for cardiovascular risk factors in 2008 showing obesity rates of 33 per cent for males and 38 per cent for females, indicating a high proportion at risk from diabetes and hypertension. (Informa Exhibitions, Life Sciences, 2012)

What is the driving change within the regions health care providers?
I would say meeting the needs of the growing population of the city and the advancing equipment within the health sector further develops the health care system. Regarding the regulatory changes, the coordination of the health authority with SEHA and HAAD are working much closer together as the health system develops and advances to meet the expectations of the population. New technologies such as e-health services are being increasingly adopted to lower healthcare costs in the region, besides improving the quality of services

Traditionally, UAE nationals and wealthy expats travelled overseas for serious medical treatments. Is SKMC planning to be the next "health tourist" destination?
Once we further develop health care services that should reduce the amount of travel outside the UAE. For example, we have a very unique pediatric cardiovascular heart program and have over 400 pediatric heart surgeries planned this year. It is the largest of its kind in this part of the world (MENA region) rivaling the program in Saudi Arabia. So our goal is to expand that even further so we are able to work with HAAD and have SEHA work with us to make sure we have the right capital to expand our programs both from a technology standpoint and the physician's standpoint, so that more health care is delivered locally than abroad. So I look at health tourism more as an elective and going abroad for cosmetic reasons. SKMC is not going down that route but rather is focused on very complex and serious medical issues that need higher technology and a skilled set of physicians-Emiratis with 4 to 5 years of training on heart surgeries alone. SKMC's kidney transplant program is the only one of its kind in the UAE. Moreover, SKMC's pediatric cardiac surgery program reached 1500 surgeries conducted since its inception in 2007, offering the chance of a happy and fulfilling life for children with congenital heart disorders.

Closing

What are your aspirations for the future of SKMC? What's the best part in being a CEO of an esteemed organization?
I am very fortunate and optimistic to be a CEO and work with so many great Emirati leaders that have taught me tremendous amount I learn every day and I have so much value brought to me both professionally and personally by working with this fascinating culture. I am very confident about the future with the direction of SEHA and Cleveland Clinic. The development of strategies to attract and retain professionals as well the governments support in heading the 2030 vision to make the UAE. Public Private Partnership such as SKMC with Cleveland clinic will surely aid in the development of the healthcare sector. SKMC will continue to provide comprehensive healthcare services in all of the disciplines relevant to the needs and priorities of the community to attain the highest levels of patient satisfaction and be the number one hospital in the UAE to deliver excellent patient care and services to the national population.

With improved patient experience efforts, unique programs and milestone surgeries, recognitions and awards, advancements in technology and infrastructure, the Emiratization initiative and increased operational excellence shows that SKMC can count itself amongst the best healthcare providers in the country, and the world.

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