Hopkins Medicine Magazine - go home
Current Issue Past Issues Talk to Us About the Magazine Search
an online version of the magazine Fall 2007
Features
Desert Bloom, illustration by Stephanie Dalton Cowan
 
  Halfway around the world, in the United Arab Emirates’ most prestigious hospital, the century-old Hopkins mission is taking fresh and unexpected turns. But can this exotic hybrid sustain its rapid growth as privatization approaches?

By LINDSAY ROYLANCE
 
 
 
 

The blinding afternoon light beats heavily against the whitewashed walls of Tawam Hospital.

A cluster of date palms shades the summer sun from sneaking past the meeting room’s tinted windows, but the waiting employees still seem flushed, anxiously wondering what the American CEO is about to tell them.

“I’ve been surprised by some of the things I’ve seen and heard around this hospital,” Michael Heindel begins, as his staff members slip each other glances. In the characteristic, straight-shooting style that’s earned him far-reaching respect in health care, Heindel lays bare to the room some alarming patient complaints. A polyclinic (outpatient center) patient waited three hours without an update; an admissions clerk shoved forms and barked orders at patients without looking up. The list goes on.

“Has anyone heard of the 1-10-100 rule?” Heindel ventures, part motivational speaker, part stern-but-caring parent. “If you fix the problem, it stops there. If you brush it aside, the patient takes it to the next level—your supervisor—and by then it’s 10 times worse. By the time it gets to me, it’s a hundred times worse, and I have to calm them down and figure out how to fix it.”

The “Aha!” moment comes as Heindel unveils his aggressive, hospital-wide push for the most American of concepts, but one that’s new here: Treat the patient like family. “Health care is changing in this country. Up until now, there’s been an attitude of, Hey it’s free, so take it or leave it. But competition is coming. And the only thing separating us from them is you.”

Michael Heindel
> Michael Heindel.

Heindel’s one-year mark at the helm of the Hopkins-managed hospital arrived this July, and with it came word that other American medical centers are muscling into the Emirati health care sector, lured by the government’s announced moves toward privatization. So far, Tawam is ahead of the game. The vision that entwines Johns Hopkins and Tawam’s owner, the Health Authority of Abu Dhabi (HAAD), has set the stage for radical upgrades to medical quality and public health in a country that has already profited from similar forward thinking in the commercial sector.

The fact that the Hopkins team and their local colleagues are quickly hitting higher marks illustrates their cohesiveness—and the tenacity of the Hopkins mission in a place far from its origins. But as Heindel and company continue to infuse Tawam with Hopkins’ intellectual capital, they must also prepare its 3,000 employees, a complex blend of Emirati nationals and expatriates from some 60 countries, for the impending arrival of privatized health care.

 

Less than 50 years ago, cradled in the southeastern dip of the Arabian Peninsula, the United Arab Emirates was a simple cluster of sheikhdoms living in Bedouin tribal tradition. Poor and undeveloped, the British protectorate scraped by on fishing, pearl diving and simple agriculture in the scattered desert oases—until the discovery of oil in 1959.

Sheikh Zayed bin Sultan Al Nahyan, the Abu Dhabi royal tapped to rule the inland oasis of Al Ain during that era, earned regional respect for upgrading agriculture and bringing rapid prosperity. He succeeded his brother as the emirate’s ruler in 1966 and in 1971 was a cohesive force in bringing together seven of the sheikhdoms, including Abu Dhabi and Dubai, to form the United Arab Emirates. Sheikh Zayed became president as ruler of the largest emirate and oil producer, while the ruler of Dubai, the region’s commercial center, became vice president and prime minister.

Oil revenues ballooned. Sheikh Zayed ushered in large-scale construction and a free national health care system, building roads and schools, housing and hospitals, far beyond the cities and deep into the desert. Al Ain’s prestigious Tawam Hospital, built in the late 1970s, was the crown jewel of this boom.

But over the next quarter-century, the population more than quadrupled as foreign workers from surrounding Arab states and Iran, Pakistan, India, Bangladesh, Afghanistan and the Philippines poured in to build this infrastructure. This surge, along with a lack of advanced services, both taxed the health system and prompted many nationals to seek care abroad.

For the last 10 years, the UAE has sent hundreds of patients, including members of the royal family, to Johns Hopkins’ facilities in Baltimore and Singapore, paying cash in full for their treatment.

But that wouldn’t work long term. Intent on channeling spending away from foreign hospitals and into improving their own, Sheikh Zayed, who died in 2004, and his son and successor, Sheikh Khalifa bin Zayed Al Nahyan, called on Hopkins to help. “We wanted a long-term relationship that would empower our health professionals with tools to provide high-quality services and educate future generations,” says Ahmed Mubarak Al-Mazroei, M.D., the royally appointed chief executive officer of HAAD.

 
JHMI International's Sharaf Shaleh, left, with a colleague at Tawam Hospital.
United Arab Emirates

Location: Middle East, bordering the Gulf of Oman and the Persian Gulf, between Oman and Saudi Arabia
Government: Federation of seven emirates (Abu Dhabi, Dubai, Sharjah, Umm al-Qaiwain, Ajman, Fujairah and Ras al-Khaimah) with one advisory body (Federal National Council)
Capital: Abu Dhabi
Language: Arabic
Currency: UAE dirham (AED3.67 = US$1)
GDP (2006): $129.4 billion (30% directly based on oil and gas output)
Independence: Dec. 2, 1971 (from United Kingdom)
Area: 83,600 sq. km. (slightly smaller than Maine)
Average temperatures: 79 degrees (Oct.–March); 95 degrees (April–Sept.)
Annual rainfall: 2.5 inches
Population (2005): 4.4 million
Median age: 30.1 years
Ethnic groups: Emirati 19%, other Arab and Iranian 23%, South Asian 50%, other expatriates (includes Westerners and East Asians) 8%

 
Tawam Hospital
Tawam Hospital
Operating budget: 820 million dirham (US$223 million)
Official language: English
Employees: 3,000 (60+ countries)
Inpatient admissions (2006): 21,687 (up 55% from 2002)
Outpatient visits (2006): 437,450
ER visits/year: 99,456
Dialysis treatments/year: 18,554
Births/year: 3,904

Last year, Johns Hopkins Medicine International signed a 10-year affiliation agreement with HAAD that includes complete managerial oversight of the 468-bed Tawam Hospital, three primary care clinics and a large dental facility around Al Ain, plus a 25-bed community hospital in the desert village of Al Wagan. The contract also outlines plans for an oncology center of excellence that will serve as a referral hub for the Gulf region.

“What we do there will have a transformative impact on the country’s health care system,” says Mohan Chellappa, JHM International’s vice president for global strategy, who played a significant role in building the relationship with the royal family.

Until this agreement, International had expanded to nearly every corner of the globe through academic and clinical advisement projects—but never hospital management. Now, says former International CEO Steve Thompson, who stepped down in July to focus on his role as JHM’s senior vice president, “we’ve gone far beyond just attracting foreign patients to East Baltimore. International has achieved the skill for leveraging the full powers of our institution’s intellectual capital.”

Thompson’s former chief operating officer and current International CEO, Harris Benny, served as Tawam’s interim CEO before hiring Michael Heindel—a registered nurse with an MBA and a 35-year career running hospitals in the United States, Singapore, Saudi Arabia, Thailand and China. A decade earlier, Benny and Chellappa had worked with Heindel at a Singapore hospital he managed for Tenet Corporation. They knew he was the best person for the job.

By his six-month anniversary, Heindel had proved them right. His management team was in place, and things were moving quickly.

 

The walk from the blue glass and steel overhang of Tawam’s VIP entrance to Michael Heindel’s office takes visitors past the information desk, where an Emirati receptionist nods in greeting, her eyes smiling through a black veil.

The country’s progressive diversity is evident along the breezy, well-scrubbed corridors. One woman is fully covered, with only her eyes peering through; another covers her hair with a hijab, leaving her face bare. And still another has her face and hair free of any covering as she sits in a female-only waiting area behind a latticed screen. Emirati men in crisp white dishdashas, Africans in bright gowns and South Asians wearing flowing shalwar kameez outfits are as commonplace as those in Western dress.

Around the corner in Heindel’s reception area, the executive porter—a combination errand man and waiter—stands at attention with a gleaming Arabic coffee pot. Offering coffee is a sign of peace, so he takes a gold-rimmed, espresso-size cup from the stack and fills it with cardamom-scented brew. He remains at attention until the visitor rattles the empty cup, a signal that no further coffee is desired.

Heindel is in his office, a serene place accented by cool marble and black leather. It’s so tranquil, in fact, that it belies the incredible sea change that’s swept Tawam Hospital since he came to town.

Quality Manager Ahlam Mohammad Al Sheiban
Facilities Manager Hamad Al Ahbabi
> One of Hopkins' goals is to train and promote local talents, such as Quality Manager Ahlam Mohammad Al Sheiban, left, and Facilities Manager Hamad Al Ahbabi, into positions of leadership.

“When I first got here,” Heindel remembers, “there were enough islands of greatness to make it a good hospital. But these well-intentioned people had no mentoring and no leadership, and the dead wood in the organization kept them trapped where they couldn’t make a difference. There were weak management accounting systems, no business plan, no performance measures, no sense of ownership and no accountability. It was time to fix the house.”

So Heindel crafted a dream team he knew would not only steer each department in the right direction but also mentor and groom talented nationals to take the reins down the road.

He lured his chief operations officer, Brian DeFrancesca, away from the Bangkok hospital that Heindel had left him to run. He convinced education specialist Tas Pepito, a lifelong friend he’d worked with in Saudi Arabia, to leave an ideal job in Florida. Heindel’s time in Bangkok also led him to a patient affairs and public relations manager, Alec Napier, and an information technology specialist, Ed Lembcke, while Hopkins recommendations pointed him to Jack Borders as chief medical officer and Steve Matarelli as chief nursing officer.

“To work here is a once-in-a-lifetime opportunity,” says DeFrancesca. “You have a good facility, good personnel, good medicine, a region that’s not short on cash, space for expansion and a bunch of Hopkins to sprinkle into it. It’s the perfect storm of health care.”

In their first few months as a team, the hospital has reduced waiting time in both male and female areas of the polyclinic from three hours to 30 minutes. The turnaround time for MRI results dropped from six weeks to 15 days, and the overall length of stay fell from six to 4.6 days. Tawam also received Joint Commission International accreditation. “Relative to the rest of the country, this is great,” says Heindel. “But it’s still not where we want it.”

Heindel is now counting on Borders, a Hopkins-trained otolaryngologist/head and neck surgeon, to take the standard of care to the next level by merging Tawam’s existing medical expertise with Hopkins’. Borders says that among the physicians he inherited—350 nationals and expatriates with a wide range of credentials—there are plenty of bright spots. The problem, as with much of the hospital, was that internal politics had stymied many potential performers.

Take internist Riad Abdel Karim, a Palestinian who graduated from the top of his class at UCLA’s medical school. He moved to the UAE because he wanted to raise his family in a Muslim society. Under the hospital’s old system of favoritism, he was overlooked for promotion. But Borders recognized his talent and made him his deputy. With Karim there, Borders says, a million problems go away because “he understands what we’re trying to do.” That very day Karim sent him a well-argued e-mail about how to better negotiate transfer between services. “All I had to do was unleash him.”

The hospital is blessed with a cadre of well-trained, well-traveled talents in a variety of disciplines, explains Heindel. “These guys didn’t go to Podunk U,” he says. “They’ve been to Yale, Hopkins, Harvard. As we send the dead wood packing, these guys are shooting to the surface.”

And, unlike in other, more conservative Muslim societies, women are among the rising stars. Dubai-native Ahlam Mohammad Al Sheiban, for example, became head of quality management soon after Hopkins arrived. She’s now a critical part of the team, leading safety assessments and infusing the institution with the American “culture of safety” philosophy. Nurses, too, are adapting quickly to such American concepts as evidence-based practice and critical thinking, says Matarelli, the chief nursing officer.

To keep practitioners’ skill bases current and further reinforce the budding Hopkins-Tawam connection, education specialist Pepito has kept a steady stream of physicians, nurses and other health care specialists coming from Baltimore to lecture and advise on everything from infection control to the latest research on Marfan syndrome. “The energy that comes off those visits is incredible,” says Pepito. “People here talk about their lectures for weeks afterward. And that same energy goes back to Hopkins, because visitors experience the thirst for knowledge here.”

But Borders wants to go a step further and recruit Hopkins-trained physicians to work here as heads of key clinical departments. Hopkins vascular surgeon Heitham Hassoun has already made the leap and is now laying the groundwork for Tawam’s vascular program, a steppingstone to a future cardiovascular department.

More are sure to follow, predicts Borders, because the draw of working at Tawam lies beyond monetary perks. “Most doctors are in this to make a difference,” he says. “But in the U.S., that’s not always easy, between the paperwork and the lawyers and the 50 other people in your zip code who do the same thing. Here, you can use your hard-earned expertise—in a very dramatic way—to bridge the gap between abundant resources and extreme need. It’s absolutely addictive.”

Borders made a media splash a few months ago when he performed the UAE’s first tracheal reconstruction surgery and drastically improved a 10-year-old’s life. Even more recently, he invented a repair for a 7-year-old’s cleft epiglottis, a rare congenital abnormality that would have killed the child.

Such abnormalities, while all but unheard of in the United States, are quite common in this small, consanguineous country. So too are end-stage renal disease and diabetes, cardiac disease, hypertension, stroke and stage IV cancer—especially lung, prostate and breast, but also cancers rarely seen in the United States, such as nasopharyngeal.

Newspaper headlines confirm a high incidence of speed-related traffic accidents that not only kill but maim, creating a large need for rehabilitation programs.

There’s also a desperate need for health campaigns against smoking, fatty foods and driving without a seatbelt, and for the promotion of early screening and preventive medicine. But these can be delicate subjects in a culture where patients’ families often prefer not to trouble their loved one with the details of their illness—health is “in God’s hands.”

Napier, the patient affairs and public relations manager, first tested the culture’s adaptability to American medicine when the hospital rolled out its first visitation policy. Visiting the sick is a Muslim “good deed” that can escalate into a large-scale event. Dozens of people bearing dates and chocolates surround the patient, lay carpets down and feast on home cooking. But the need to safeguard patient care outweighed preserving tradition.

Through newspaper ads, radio discussions and community meetings, Napier got the word out that visiting restrictions would improve patient care. It worked. “We expected pushback,” says Heindel, “but people appreciated that we were trying to help, as long we were a little flexible and sensitive to where we are.”

COO DeFrancesca discovered that, too, as he made the case to purchase a mobile digital mammography unit—a move that could save many lives in the UAE, where more than two-thirds of breast cancer cases are already in advanced stages. David James, a British expat who for decades has run Tawam’s clinical services, pointed out that the van couldn’t pull right up to the front of the shopping mall, university or other public places; women would be too embarrassed to enter. Yet if the van parked more covertly, they might not know it was there. Finally, James and DeFrancesca came up with an even better model: a one-stop shop for several types of screenings, including mammography, bone density and diabetes.

Sheikha Fatima bint Mubarak, wife of the late Sheikh Zayed, enthusiastically funded eight vans. Now, these mobile services are poised to have far-reaching, unprecedented effects on public health—and on the hospital’s reputation in the community. “The last time foreigners reached out to people in the desert, they were in it for the oil,” explains DeFrancesca. “We’re here to save lives.”

 

Symbols of UAE’s past linger despite its explosive progress -- camels in a pickup truck.
> Symbols of UAE’s past linger despite its explosive progress.

It’s another 120-degree afternoon, yet Al Ain’s dry summer heat is refreshing compared to the suffocating coastal humidity of Dubai and Abu Dhabi. Beyond Tawam Hospital, forestation efforts dot the undulating, red desert dunes with irrigated green. Dusty camel markets coexist with upscale shopping malls and Starbucks. In the distance, wind-carved rock formations jut out of the sand at odd angles before giving way to the 4,000-foot Jebel Hafeet, the country’s second-highest point.

A male voice echoes through the cool of the air-conditioned hospital, calling Muslim faithful to the third prayer of the day. Allah u Akbar, he sings. God is great. Shoes are left in obedient piles outside prayer rooms.

Heindel is in his office with his chief financial officer, Saeed Al Kuwaiti, a Western-trained national and the only non-Hopkins member of the senior executive management team. Under ever-present portraits of the country’s revered Sheikh Zayed, Sheikh Khalifa and Crown Prince Sheikh Mohammed, the two discuss the emirate’s new health insurance scheme.

This is part of the government’s move to fee-for-service and the privatization of health care—an American-style model that splits risk with employers—and one leaders hope will ease the ever-expanding burden of free care. “The royal family is too generous to move completely away from subsidizing care,” Al Kuwaiti explains. “They just want a way to better regulate it.”

The system is also creating a more competitive landscape. The health authority is already outsourcing management for other big hospitals in the emirate: a Thai company will run Mafraq Hospital, and Cleveland Clinic will run Sheikh Khalifa Hospital, plus build a totally new hospital, all in the capital. Meanwhile, Medical University of Vienna and Vamed will manage Al Ain Hospital, a secondary facility not far from Tawam.

That’s exactly why after the Hopkins agreement was signed, Heindel put together a three-year business plan that included an ambitious, US$3 billion master plan to upgrade the Tawam campus. The current facility, he explains, is well-maintained and well-equipped, but it’s 30 years old and has sustained as many renovations as it can handle. “Expansion within the current building would be like trying to put a bowling ball in a marble bag,” says Heindel. “You can’t knock out another wall without the roof falling down.”

One new building, an oncology center of excellence, is already in the works as part of the management agreement. But Heindel, with the help of Hopkins and Tawam teams and a Baltimore architecture firm, is also envisioning a totally new campus that will address the needs of the entire Gulf region—launching Tawam onto an international stage that projects 75 years into the future.

Thus far, the plans are still hush-hush beyond a proposed diagnostic and rehabilitation center of excellence, largely because the team is awaiting approval from the government. If approved, Heindel predicts, Tawam will be on its way to regional, if not world, landmark status.

“Our synergy is really starting to click,” he says. “The handcuffs are off, people are empowered, and we’re getting things done.” Still, he cautions, the sweeping clinical, structural and organizational changes are for naught until the hospital is injected with an attitude of service.

Back in the meeting room, Heindel is introducing Sharaf Saleh to the gathered employees. Several people smile and nod; they’ve seen him around the hospital. Heindel borrowed the Hopkins veteran for several months to lead customer service training. The charismatic Saleh, a tall, Arabic-speaking Muslim originally from Sudan, has a decade of experience serving Hopkins patients from this part of the world. Heindel is confident that the staff will respond well to him as he strives to instill respect and compassion into the way they treat patients—and each other.

As the CEO wraps up the meeting, most of the employees seem inspired. One man remarks that he could see how it will bring good to the hospital. And that’s all Heindel wants: “to one day leave behind something better than when we came.” Inshallah, as they say in the desert. God willing. *

 

Destination: Al Ain

Rusty and Sara SchlessmanLast December, Hopkins employees Rusty and Sara Schlessman left their cozy home in the Baltimore ’burbs for a four-bedroom, Arabian-style villa in the desert oasis of Al Ain.

Rusty, 30, formerly a project administrator for the surgery department, is now acting CEO of the 25-bed community hospital that falls under the Hopkins-Tawam agreement. Twice a day, a hospital driver chauffeurs him between Al Ain and the desert village of Al Wagan on a desolate, 56-mile stretch along the UAE-Omani border marked only by wind-swept dunes, camel ranches and date farms.

Meanwhile, Sara, 34, works at Tawam Hospital as clinical resource nurse for male and female surgery. She stepped down from her position as a nurse practitioner in Hopkins’ outpatient otolaryngology clinic to make the move.

The UAE attracts expat professionals like the Schlessmans with nearly tax-free pay and hefty benefits packages that include annual allowances for housing (a junior-level doctor and his family, for example, would get $15,000), transport, utilities, education, health care—even $8,000 for furniture—plus a yearly air ticket home.

It’s a long way from the couple’s native Kansas City, but, they say, “How else could we sunbathe in Muscat or shop in Dubai?”

 

Lindsay Roylance

 
 
 
 
Features
 A Silver Bullet for Blake
 Desert Bloom
 'No One Dies Tonight'
 
Departments
 Circling the Dome
 Medical Rounds
 Bench Press
 Annals of Hopkins
 
Class Notes
 The Stobo Touch
 
Opinions
 Learning Curve
 Post-Op
 
Johns Hopkins Medicine

© The Johns Hopkins University 2007