When Dr. Manish Kohli surveyed an empty 23-acre plot of sand in 2009, he had no way of picturing the massive building that would be erected there — a 409,000 square-meter facility consisting of a towering stack of metal and glass blocks requiring more steel than the tallest building in the world. Kohli was soon joined by a team of 50, which would grow to a staff of 5,000 in just over six years. That staff now operates what is arguably the most advanced medical center in the MENA region, Cleveland Clinic Abu Dhabi (CCAD), a sister to Cleveland Clinic’s main campus in Ohio.
Cleveland Clinic is one of a growing wave of Western medical institutions expanding into the Middle East. Among those that have jumped in are Houston Methodist Hospital, Children’s National Health System, and longtime global player Johns Hopkins Medicine International, which all manage one or more hospitals in the UAE, and in some cases in other GCC countries. But Cleveland Clinic took a more ambitious approach. Rather than building affiliations with existing institutions, as the others did, it built a fully self-branded medical center from scratch, and manages and operates it.
Placing its name front and center on a prominent hospital 11,300 kilometers away from the mother ship could be seen as a significant risk for an institution revered for the quality of its clinical care and high levels of patient satisfaction. Kohli, the first Cleveland Clinic physician on the project and one of the effort’s ongoing leaders, was all too aware of the challenges of transferring clinical excellence and precise standards to a distant location with no staff in place, within a very different culture. There was no handbook or precedent to draw on, Kohli notes. “We were trying to build the airplane as we were flying it,” he admits. “But the expectation was that on day one, we would deliver the same level of care to patients here as they would find walking in the door in Ohio.”
By the numbers, CCAD is an impressive establishment. The 364-bed facility offers more than 30 medical and surgical specialties over five clinical floors, 13 departmental institutes, three diagnostic and treatment levels, and 13 floors of critical and acute inpatient units. All CCAD physicians are North American/European Board Certified, or hold an equivalent certification. In 2016 — the clinic’s first full year — CCAD handled 285,000 outpatient visits and 5,422 admissions. Each of CCAD’s 13 institutes has performed advanced treatments previously available only abroad, such as robotic mitral valve repairs, multilobar resections for epilepsy, and 3D-printed replacements for cardiac procedures. The CCAD Neurological Institute was recognized as the only Stroke Center in the Abu Dhabi by the Emirate’s Health Authority after only seven months of operation. (Thanks to the building’s striking appearance, it’s also become Abu Dhabi’s third-most-visited landmark, according to the Abu Dhabi Tourism & Culture Authority.)
Particularly significant, the breadth and high level of specialty services, along with state-of-the-art interior and patient-room design from construction and engineering firm HDR, attracted some 1,200 patients from other countries to CCAD in 2016. “Having patients come from abroad to the Middle East is a reversal of the established trend,” says CCAD CEO Tomislav Mihaljevic. Indeed, the driving force behind the trend to bring Western medical institutions into healthcare overseas has been the interest of Middle East governments in slowing the flow of Middle East patients traveling to the West to get types and quality of care that previously couldn’t easily be had at home. In 2012, the Cleveland Clinic treated 3,200 foreign patients at its main campus in Ohio, and about 35 percent of those patients came from the Middle East, numbers that aren’t unusual for a top U.S. medical center. But in addition to the inconveniences and emotional demands of being treated far from home, medical travel incurs a hefty financial cost that must be borne by patients’ families, insurance companies, or the government, or often a combination of the three. “Instead of the UAE spending one- to two-billion [US] dollars annually sending patients abroad for care, we can step in and fill the healthcare void,” says Kohli.
Easier said than done. One of the key challenges of overseas hospital partnerships is finding, training and managing staff capable of delivering consistently high-quality, safe, efficient care in regions that may suffer from shortages of highly trained and experienced clinicians, technicians and administrators. That requirement was all the more daunting for CCAD, given that it had no existing staff in place to draw on, and that the results would inevitably be measured against Cleveland Clinic’s own performance. Any severe shortcomings or lapses could present a reputational catastrophe for the brand.
One answer, says Mihaljevic, was simply to bring in large numbers of present and former Cleveland Clinic staff. “We’ve brought Cleveland Clinic care here by bringing Cleveland Clinic people here,” he says. “It’s not just our name on the building.” The entire CCAD staff live and work in Abu Dhabi — there are no visiting or rotating staff in the roster — though only 15.5 percent are UAE nationals. One-third of the 350 physicians currently at CCAD, selected out of a pool of 11,000 applicants, have worked at the Cleveland Clinic main campus at some point, as well as 82 percent of the departmental heads.
What’s more, CCAD staff has direct access to critical main-campus resources, including access to main-campus EHR systems and other IT resources. That means clinical and administrative processes could more easily be replicated and maintained. To foster collaboration between the two campuses, all CCAD doctors are allotted time every year to visit the main campus, and can email or call their counterparts in Ohio for same-day consultations. For especially complex cases, they can summon the expertise of a full specialty team on the main campus. “It’s become a very common resource for us,” says Dr. Yaser Abu El-Sameed, a specialist in the CCAD pulmonary institute who recently has been working closely with the bronchoscopy group in Ohio. Perhaps the greatest tribute to the connection between the two campuses is the fact that Mihaljevic is slated to take over as CEO of the main Cleveland Clinic campus upon Toby Cosgrove’s retirement at the end of 2017.
Still, there have been a few significant and very un-Cleveland-Clinic-like wrinkles to sort out. In the short time since opening to patients in 2015, CCAD has been plagued with scheduling snafus, with some patients forced to wait up to three months to see a specialist. CCAD’s Chief Administrative Officer, Abdullah Al Shamsi, addressed the complaints by promising to double the number of physicians from the 200 available a year ago to 400 by the end of 2017, tailoring the hires to the bottlenecked specialties.
The risk isn’t only to Cleveland Clinic’s reputation for high-quality, high-touch patient care. There’s also the question of whether Western higher-cost, higher-tech medicine makes business sense in other markets. That’s what tripped up the Mayo Clinic when it opened a cardiac clinic in 2005 at Dubai Healthcare City, a health campus of 120 medical facilities. The Mayo closed the clinic five years later, citing a lack of patient volume needed to justify the expense of advanced technology and U.S.-trained personnel.
To address the financial risk and make the numbers work, Cleveland Clinic struck a deal with capital investment firm Mubadala, under which Mubadala paid for CCAD’s design and construction and undertook ownership of the new hospital. Mubadala has also served as an important advisor, thanks to local healthcare experience gained by being the primary investor in the Abu Dhabi Telemedicine Center, Imperial College London Diabetes Center, National Reference Laboratory, and Tawam Molecular Imaging Centre, among other healthcare institutions. “I cannot emphasize enough how important it is for any foreign institution to have a trustworthy and capable partner,” says Mihaljevic. He adds he has also worked to keep strong ties to the Health Authority of Abu Dhabi, which is being pushed by a grand government scheme called Economic Vision 2030 to establish a sustainable, region-leading healthcare sector in the Emirate.
Still, some observers familiar with the local healthcare market question whether CCAD will be able to bring in enough revenues to cover the high costs of its business model. “In 2010, their strategy made sense,” says Rebecca Samuel, director of consulting for ICME Healthcare, a German healthcare integrator with offices in Abu Dhabi. “But by the time they opened, the market had changed. There’s a lot more emphasis on being efficient and economical, and insurance companies are a lot more cost-conscious now.” Samuel adds that the pressure on CCAD to keep up patient volumes to fully utilize the facility will require taking in more and more relatively low-paying patients.
Cultural challenges abound as well. Expats make up 80 percent of the UAE population, and 23 percent of CCAD’s patients, making the patient demographic remarkably varied. “We couldn’t just copy and paste the Cleveland Clinic model” says Mihaljevic. “We needed to adapt.” Segregation of men and women, for example, which is the cultural standard throughout the region, has been challenging. The original design team, for instance, had to create separate waiting rooms for men and women — though the two rooms are served by the same patient-services station, ensuring equitable service. And according to El-Sameed, the CCAD pulmonary specialist, practicing medicine within Middle East’s strong family-oriented culture means having to explain the reasoning behind medical decisions to 15–30 family members. Thus the patient rooms were designed with visiting areas that enable small throngs of visitors to remain and talk to caregivers without restricting caregiver access to patients. Patients’ attitude toward physicians is a bit different, too, says El-Sameed, though that didn’t require special design or take much getting used to. “Patients consider you family after the first few visits,” he says. “I have patients insisting that I attend their wedding.”
So far, at least, CCAD is talking about expanding the scope of its services. For one thing, there is a significant unmet demand for primary and emergency care in the region. According to a 2016 Health Authority report, Abu Dhabi is short 77 emergency physicians and 73 emergency bays, compounded by a lack of adequately trained personnel in the few emergency departments currently operating. The demand is only expected to rise, due in part to rates of major car-accident trauma projected to surpass those of Australia and the U.K., pushed by the high proportion of young adult males in the local population. El-Sameed notes that while he and many of his fellow specialists came to CCAD to provide tertiary and quaternary care, they end up having to provide a fair amount of primary care. “You just have to step in,” he says.
Mihaljevic says the next frontier for CCAD is clinical teaching and research. The facility has already received designation as a research hospital by a regulatory commission in Abu Dhabi, and has established an internal review board for clinical trials. In conjunction with Cleveland Clinic’s Lerner College of Medicine, CCAD has prepared its first internship and residency programs. Mihaljevic insists CCAD will produce the next generation of UAE healthcare professionals. “To create a sustainable quality of healthcare delivery here is a big portion of our mission,” he says.
Time will tell. But if Cleveland Clinic Abu Dhabi succeeds on all fronts, including financial, more high-powered Western institutions are likely to begin rethinking their emphasis on helping overseas hospitals instead of just building their own.
— Alex Freedman
Alex Freedman is a freelance healthcare writer based in Portland, Oregon.
For a look at how Western healthcare institutions are handling risk when considering overseas partnerships, see these articles from our archives:
"Turning Risk Into Opportunity in International Healthcare Partnerships," by GHCi's Steven J. Thompson
"U.S. Hospitals with International Patients Enter Overseas Improvement Projects," by Teresa L. Johnson