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Global Collaborative Healthcare - Rebirth in Abu Dhabi
Rebirth in Abu Dhabi
David H. Freedman
Date: June 20, 2014
Left to right, Marwa Zidan, who recently earned a B.S. in Corniche’s new 18-month midwifery program, Mariam Al Mazrouei, Corniche Hospital’s chief operating officer, and Mona Kazem, whose three children were all born at Corniche, including 2-day-old Khaled.
Photo by Michelle Loibner
When Ron Lavater took over as CEO of Corniche Hospital in Abu Dhabi in early 2009, he was confronted with a simultaneously exciting and daunting task: Transform a good health care institution into one of the best in its field of maternal and neonatal medicine. Doing so would require knitting diverse cultures, medical practices and organizational styles into a cohesive whole in an effort to raise health care standards to the highest possible levels in a part of the world where relatively few hospitals had attained them.
Lavater came armed with a 4-inch-thick “gap analysis” binder prepared by his colleagues at Johns Hopkins Medicine International as part of its five-year agreement formed at the end of 2007 with the quasi-governmental Abu Dhabi Health Services Company (SEHA) to manage Corniche Hospital.
Located in Abu Dhabi City, capital of the United Arab Emirates (UAE), Corniche opened at its present site in 1984. It functioned as the busiest tertiary care maternity hospital and neonatal service in the region, with 8,500 births and 1,000 neonatal intensive care unit (NICU) admissions annually.
“We weren’t starting a new hospital, and we weren’t taking over a facility that was in shambles,” Lavater recalls. “It was a good facility that was providing good care for decades. As a hospital leader, you respect the history and then build upon it.
“From the very beginning, we sat down with our government partners and outlined a multiyear plan about what was high on their priority list, what was going to be defined as success during this five-year period of management and what was needed to have a smooth transition at the conclusion of the contract back to SEHA management. We developed Corniche’s vision with SEHA with sustainability in mind.”
On Lavater’s agenda: Establish a more innovative style of management; raise the level of evidence-based clinical practice, especially with regard to patient safety; update physical facilities; encourage collaboration between the nursing and medical staffs; build a culture of service excellence; develop a meaningful Emirati succession plan; and, perhaps most important, create the elements of a teaching hospital with training programs that would produce the next generation of caregivers from the area.
As more increasingly industrialized—or recently industrialized—nations such as the UAE gain the resources and motivation to upgrade their hospitals and health care systems, they are seeking international collaborators who have experience with state-of-the-art hospitals.
Since its 1998 founding, Johns Hopkins Medicine International has been building relationships with hospitals worldwide, providing not only administration—as is the case with Corniche and two other Abu Dhabi facilities under separate contracts—but also tapping into its extensive knowledge base to address an array of needs—medicine, nursing, public health, education, research—to improve overall health care delivery. Johns Hopkins Medicine International’s past and current collaborations include hospitals in North America, Latin America, Asia and the Middle East.
One of the first things that Lavater and his Johns Hopkins Medicine International administrative team emphasized to Corniche’s staff members, who represented upward of 50 different countries, was that Johns Hopkins’ practices at its own hospitals would not be arbitrarily imposed as part of its new management agreement.
“When you assume leadership of a hospital with more than 1,200 employees, you’re not going to build a team or build a commitment from the employees if you say, ‘There’s a new sheriff in town, and we’re doing everything differently,’” Lavater explains. “You have to listen, you have to see what works and what doesn’t work.”
At a town hall meeting early in the collaboration, for example, long-time midwives at Corniche expressed concern that the hospital’s midwifery model might be replaced by a physician-led one.
As Lavater recalls: “One midwife raised her hand and asked, ‘Are you going to change everything? Are you going to change the way that we provide care, change the midwifery-led delivery model?’
“And I turned it around and asked, ‘Do you provide good and safe care?’ And she said, ‘Yes.’
“‘And what do our patients say?’ And she told me, ‘They like it.’
“So I said, ‘Well, then, why would we change that? Why would Hopkins come here and change something that’s working?’”
He pointed out, however, that the existing delivery model could be enhanced and improved, making it more sustainable and successful and thereby ensuring its continuation for many years.
“We took the best of what was already there and combined it with what might be of benefit from the Hopkins system in order to provide the best for people in Abu Dhabi,” says Lynda Mikalauskas, Corniche’s chief clinical officer during Johns Hopkins Medicine International management. “In actual fact, there were very few changes made from a midwifery and nursing standpoint. The midwifery model continued in the same way that it had.”
Initially, the biggest challenge the new team faced was recruiting high-quality physicians, nurses and other professionals to fill existing personnel gaps and to grow the staff to meet the ambitious goals for advancing the hospital’s capabilities. In many parts of the world, there are rarely enough local medical professionals to meet a hospital’s needs, and the shortage is often acute. At Corniche Hospital, more than 95 percent of the clinical staff and about three-quarters of the nonclinical staff are expatriates.
Paul Martin, Corniche’s chief human resources officer from 2009 to 2012 and now a corporate HR business partner at SEHA, ticks off several critical areas that required beefed-up staffing: medical doctors, midwives and NICU nurses. There was also the need for “Emiratization”—hiring UAE nationals.
With regard to doctors, “We wanted to expand the Western influence in terms of people who had been trained and [had] experience in North America or Europe,” he notes. Accordingly, Corniche recruited the most qualified candidates available from the U.S., Canada and U.K. By far the most difficult personnel to find were midwives and NICU nurses, “because everyone in the world is trying to find those care providers,” he says. Some posts took a year to fill.
Martin’s efforts toward Emiratization paid off handsomely. By the time he completed his stint at Corniche, the number of UAE nationals working there—mostly in nonclinical positions—increased from 12 to 120.
Simultaneously, Lavater worked to restructure Corniche’s management culture to one centered on teams, with decision-making and responsibility pushed down to 30 key frontline managers and clinicians rather than being centralized in the small administrative team. Through weekly huddles, informal gatherings and off-site meetings, “We were able to engage more with our managers and physician leaders who are running the operation,” Lavater says, “constantly reinforcing the idea that senior leadership was there to remove obstacles for them.”
As the clinical staff increased and the management system evolved, Corniche’s infrastructure underwent an extreme makeover under the leadership of chief operations officer Bassam Sayad. Crucially, the 50-bed NICU doubled in physical size, with 14 beds added and state-of-the-art equipment installed. The main entrance experienced an overhaul; the hospital’s entire first floor was refurbished, including all outpatient areas and exam rooms. Campus parking expanded by 40 percent. In addition, an off-site Women’s Health Center was constructed.
With staff and facilities in place, the administrative team turned its energies toward establishing best practices for patient care, including education and mentoring programs. The team established a two-way knowledge exchange between Corniche and Johns Hopkins Medicine. Flowing from Baltimore, a stream of world-class clinicians—experts in Ob/Gyn, neonatal care, patient safety, epidemiology and infection control—visited Corniche to provide workshops and assist staff in establishing and codifying new practices, setting up a tight communications flow within and between teams of clinicians, and conducting rounds.
Corniche physician and nursing leaders, in turn, visited Johns Hopkins, learning about patient safety, risk management and neonatal care. “It was very much a sharing experience, a move toward having a clinical community,” says Jane Kelly, Corniche’s chief of quality, who came to Johns Hopkins in Baltimore twice as part of the program. “There were lessons that we could learn from each other.”
Augmenting these efforts, Corniche set up its first dedicated patient safety office to bring a visible culture of safety to the hospital, revamped the hospital pharmacy and established medication management automation. Working from the Johns Hopkins playbook on patient safety, the team joined the Patient SafetyNet System run by the University Hospital Consortium, implemented the Modified Obstetric Early Warning System, and initiated administrator-led patient safety rounds.
Additionally, the hospital made significant strides to improve the patient experience, guided by a Johns Hopkins-designed Service Excellence program, strengthening customer communications and responsiveness.
“The customer voice is very important and a great tool for improvement,” says Dolly El Ghadban, Corniche’s patient experience manager, who visited Johns Hopkins in 2009 as part of the knowledge-sharing program. The next year, she spearheaded the launch of the hospital’s service excellence program, “customizing,” as she terms it, the Johns Hopkins model “to meet the needs of the UAE culture.”
In terms of patient quality, Corniche set out to expand subspecialization clinical services in fetal medicine, assisted reproductive services, maternal medicine, NICU respiratory therapy, clinical pharmacy, high-risk obstetrics, lactation, diabetes, dietetics, parent education and physiotherapy.
That expertise was put to the test in October 2010. Corniche made headlines when the hospital’s medical team delivered the UAE’s first live sextuplets, drawing on the skills of nearly 30 staffers from a range of subspecialties.
“This was an opportunity for a very extensive organization of the nursing service, the NICU, the operating room and the physicians to ensure that we had everything that was necessary for the babies to be born and handled one by one as they were delivered,” says Mikalauskas, now on assignment for Johns Hopkins Medicine International as a nurse consultant in Panama.
The mother was a 32-year-old Egyptian woman who had been living in Abu Dhabi with her husband when she became pregnant after undergoing fertility treatments at another facility.
After the delivery, mother and babies—three girls and three boys—stayed on at Corniche for six months, not because of any health problems (all thrived), but because the parents lacked the financial resources and the proper accommodations to care for their newborns. Hospital staff moved into high gear to resolve those difficulties, persuading the reluctant father to allow Corniche to publicize the family’s plight via the media, and then setting up a hotline and Facebook page to solicit and accept donations.
Everyone from sheikhs to companies to concerned Abu Dhabi citizens responded. “I was getting calls from everybody,” remembers El Ghadban, who oversaw the initiative. “We were able to provide several months’ worth of provisions, including clothing, detergent, diapers, milk and baby bottles.”
Meanwhile, Corniche worked with the Red Crescent and local government to find new housing for the family—rent-free for a year—where they took up residence in March 2011.
After recruiting Abu Dhabi’s first hospital-based public health director, it didn’t take long for Corniche to take hold of a key public health issue—newborn car safety—and create awareness around it
“As a Hopkins-managed facility, it was important for us to look beyond the hospital walls to engage in the community to promote health,” says Lavater. Though motor vehicle accidents ranked among the leading causes of death in Abu Dhabi, there were no enforced car seat regulations in place. As a result, it was standard practice for new mothers to ride home from the hospital with their newborns nestled in their laps.
Aided by input from the Johns Hopkins Bloomberg School of Public Health, in late 2009 and early 2010, the hospital worked with the UAE’s largest insurance company and the local government to create a program allowing all newborns to leave the hospital in a free car seat. Before discharge, mothers received instruction on the seats’ proper use and installation. To date, more than 18,000 infant car seats have been distributed.
Perhaps the most ambitious component of the Corniche/Johns Hopkins collaboration focused on education. “The Johns Hopkins Medicine International Abu Dhabi team was acutely aware of Johns Hopkins’ academic mission, and we wanted to bring this ethos to Corniche Hospital,” says Lavater. “From the beginning of our tenure, our long-view plan, built in partnership with SEHA, was to transform Corniche to a teaching hospital.”
Accordingly, shortly after chief medical officer Judy Lee arrived in 2009, she helped shepherd the nearly three-year process whereby Corniche was accredited by the Royal College of Obstetricians and Gynaecologists to provide advanced training in maternal and fetal medicine programs. This enabled the hospital to offer previously unavailable opportunities for advancement by establishing a rigorous framework whereby promising doctors could achieve “consultant” status.
“When our junior medical staff saw there were these opportunities—that doctors were rewarded based on merit and hard work—we had loads of applications,” says Lee, now an assistant professor in the Department of Gynecology and Obstetrics at the Johns Hopkins University School of Medicine.
From the nursing and midwifery side of the care equation, the hospital established a specialized NICU nursing education course that allows participants to complete a six-month certificate program and inaugurated a bachelor’s of applied science in midwifery program in partnership with the Higher Colleges of Technology of Abu Dhabi.
Taken together, these efforts “raised the bar for quality, evidence-based care for maternity and neonatal services in Abu Dhabi,” notes Lee. “Ultimately, for the Emiratis, we wanted to create a legacy of education for them in terms of role models for their own population—developing the Ob/Gyn physicians and midwives of the future.”
The Johns Hopkins Medicine International team members’ last project was a curious one: Make themselves redundant. All along, Lavater and his senior colleagues had been laying the groundwork for the smooth exit of Johns Hopkins from the administrative side of things, permitting SEHA and local managers to resume full responsibilities.
Paul Bosio, for instance, was hired as chief of service for obstetrics and gynecology in July 2012, with the possibility of ascending to the post of chief medical officer held by Lee. “I shadowed Dr. Lee during many of her duties throughout 2013,” he explains, “and this intensified during the month prior to her leaving.” Bosio served as interim chief medical officer through year’s end. “Along with my own past professional experience, I felt well prepared to take up the permanent position in January this year,” he says.
Mariam Al Mazrouei is among Corniche’s proudest success stories. Today the highest ranking Emirati at Corniche Hospital, she arrived in 2011 as part of the succession plan, shadowing Lavater and others in a structured mentorship environment, so she could take the reins as chief operating officer and deputy chief executive officer after the handover. “Her success is a powerful testament to our sustainble approach,” says Lavater, who now serves as a senior executive for Middle East operations with Johns Hopkins Medicine International.
On Dec. 31, 2013, the hospital staged a formal hand-over ceremony for the entire staff. The Johns Hopkins team had worked diligently for nearly a year to prepare the organization for the transition to SEHA management—and all went off without a hitch.
Looking back, says Lavater, “What I found in my five years of leading Corniche Hospital is that irrespective of a caregiver’s educational background, country of origin and native culture … all want to provide the best care to their patients.”
Michael Yockel is a Baltimore freelance writer. David H. Freedman is a contributing editor to the magazine.