Prof. Dr. Dr. h.c. Fried Oelschlegel Director of Business Development

1. Healthcare Management Forum 2008 27 – 31 January 2008Dubai International Convention and Exhibition Centre, Dubai, UAE The Ballast of structures – Lean Management as a prerequisite for global growth in Healthcare Prof. Dr. Dr. h.c. Fried Oelschlegel Director of Business Development Emaar Healthcare Dubai, 28th January 2008

2. Vision Our vision for EMAAR is its transformation into one of the most valuable companies in the world, beyond real-estate and development, irrespective of business activity.

3. To the world Emaar will be known as a company that delivers an all-encompassing quality lifestyle across the globe. Emaar will offer a one-stop global solution for every significant aspect of a multi-faceted lifestyle. Home, work, play, leisure, retail, health, education, finance, industry and more. Mission

6. What are “world class” hospitals? What are the benchmarks? How to build an effective, shareholder value adding enterprise structure? How to grow? Where to grow? With whom to grow? When to grow? Who is doing what? What about PROPCo? What about OPCo? Do we conform to the same ideals as others or are we different? i.e “think and act outside the box” How do we create “differences”? Can we learn something from the industry? What are the structural innovations in Healthcare? Do we have to put Governance and Management in Healthcare on a critical test bed? Many questions are coming up …..

7. Domain 1: Safety (9 Core / 1 Development Standard) Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents. Domain 2: Clinical & Cost Effectiveness (5 Core / 1 Dev.) Healthcare organisations ensure that clinicians continuously update skills and techniques relevant to their clinical work. Domain 3: Governance (14 Core / 15 Dev.) Healthcare organizations apply the principles of sound clinical and corporate governance. They undertake systematic risk assessment and management and support their staff through organizational and personal development programmes, which recognise the contribution and value of staff and address, where appropriate, under-representation of minority groups. Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare participate in mandatory training programmes. NHS (UK) Healthcare CommissionCore Standards Declaration 2006/2007 Domain 4: Patient focus (9 Core / 3 Dev.) Domain 5: Accessible and Responsive Care (3 Core / 1 Dev.) Domain 6: Environment and Amenities (3 Core / 1 Dev.) Domain 7: Public Health (4 Core + 1 Dev.)

8. 1. Safety C1Health care organisations protect patientsC2Health care organisations protect childrenC3Health care organisations follow NICE Interventional Procedures guidance to protect patientsC4Health care organisations keep patients, staff and visitors safeD1Health care organisations continuously and systematically review and improve all aspects of their activities that affect patient safety2. Clinical &Cost EffectivenessC5Health care organisations ensure that they conform to NICE technology appraisals, clinicians update their skills and participate in regular clinical audit activities C6Health care organisations co-operate with each otherD2Patients receive effective treatment and care 3. GovernanceC7Health care organisations apply the principles of sound clinical and corporate governanceC8Health care organisations support their staffC9Health care organisations have a systematic and planned approach to the management of recordsC10Health care organisations undertake appropriate employment checksC11Health care organisations ensure that staff are appropriately recruited and trainedC12Health care organisations which lead or participate in research apply the principles of research governanceD3Integrated governance arrangements are in placeD4Health care organisations work together to improve qualityD5Health care organisations work together with social care organisations to meet the changing health needs of their populationD6Health care organisations use effective and integrated information technology and information systemsD7Health care organisations work to enhance patient care by adopting best practice in human resources management 4. Patient FocusC13Health care organisations have systems in place to respect patient confidentiality and treat patients with dignity and respectC14Health care organisations have systems in place to deal with complaintsC15Where food is provided, health care organisations have systems in place to provide patients with choice and a balanced dietC16Health care organisations make information available to patients and the public on their servicesD8Health care organisations continually improve the patient experienceD9Patients receive timely and suitable information on treatment, care and servicesD10Patients and service users are helped to contribute to the planning of their care 5. Accessible & Responsive CareC17The views of patients and others are taken into account in designing health care servicesC18Health care organisations enable all members of the population to access services equallyC19Health care organisations ensure that patients with emergency health needs are able to access care promptlyD11Health care organisations plan and delivery health care to reflect the needs of the population and maximise patient choice 6. Care Environment and AmenitiesC20Health care services are provided in environments which promote effective care and optimise health outcomesC21Health care services are provided in well maintained and clean environmentsD12Health care is provided in environments that promote patient and staff wellbeing 7. Public HealthC22Health care organisations work in collaboration with each other and local authorities to promote, protect and improve the health of the populationC23Health care organisations have systematic and managed disease prevention and health promotion programmesC24Health care organisations protect the public by having a planned response to incidents and emergenciesD13Health care organisations act on significant health problems and health inequality issues

9. Call for patient safety, risk assessment, mandatory learning , governance & ………. I swear by Apollo the physician and Aesculapius and Hygeia and Panacea and all the gods and goddesses that, according to my ability and judgement, I will keep this Oath and this stipulation: To reckon him who taught me this Art equally dear to me as my parents, to share my substance ……and to disciples bound by a stipulation and oath, according to the Law of Medicine, but to none others. I will follow the system of regimen which according to my ability and judgement I consider for the benefit of my patients and abstain from whatever is deleterious and mischievous. With purity and with holiness I will pass my life and practice my Art. Renaissance or new vine in old pipes …? القانون في الطب"Al-Qanun fi al-Tibb For 2500 years the same problems have existed. When and how can we achieve a breakthrough? ابو علی الحسین ابن عبدالله ابن سینا Pieter Lastman (1583-1633)Hippokrates visiting Democrit in Abdera, 1622

10. or isn’t this attended to as a matter of course today ? Continuous Medical Education Patient safety & protection Clinical audit Effective treatment & care Record management Using effective information systems Employment checks; well trained staff Treating patients with dignity & respect etc……. Is talking about such basic principles really necessary?

11. There is an abundance of written papers for Clinical Standards, Regulations, Manuals, Catalogues, Guidelines, Procedures, Evidence Descriptions, and Accreditations in Healthcare – But, there is a lack of understanding, motivation, better balanced professional & ethical education and practicing in clinical weekday, empowered management and future focused leadership. There is too much industrial lobbyism, contrary interest structures and reality denial. What is the way out of this misery? We all are all aware of it but we do not talk about it.

12. More papers, more IT-programs, more regulations, more standards, more domains, more reports, more bureaucracy will not solve the problem of a pressing lack of medical quality, economic efficiency, increasing dissatisfaction of patients and frustration of medical staff. More committees, more governance, more structures, more presidents, will not bring the long sought-after management formula for more quality and efficiency – for SUSTAINABLE SUCCESS Web advanced search in Google: “Hospital Management”  15,400,000 entries (0,3 sec). So, what now?

13. There’s an old story in the Arab world, the one about the committee that was set up to create a horse and came up with a donkey. For too long, decision makers in healthcare have been plagued by what is sometimes called “analysis paralysis”. A good idea is proposed, passed around, subjected to debate, put through a battery of tests and scrutinised in the light of various possible scenarios, after which it is debated some more. Who has not had the experience: The best way to kill a good idea is to propose it to a committee. You can be sure: the idea quietly passes away from a mixture of old age and exhaustion. To avoid the metamorphosis of horse to donkey I believe I was planned somewhat differently ...

14. “I don’t consider myself to be an impatient or impulsive person, but I’ve even toyed with the idea of removing the chairs from EMAAR’s meeting rooms, thereby encouraging people to think on their feet. The times call for such measures. The time has come to act, swiftly and decisively; speed with quality, execution with efficiency - this is the goal”. The EMAAR message is … “ …..And so, every day I pepper my colleagues with questions: Can we do this quickly? Can we do it now? Can we do it right? Can we do it better than anyone else? Even if we doubt the outcome, can we try?... Are we doing this from the heart?….” The EMAAR message is :not to succumb to theold way of doing things - or not doing things.

15. The most important distinguishing feature of Dubai has been a commitment to break free from the old culture of inaction. The best intentions are meaningless without timely execution. A similar principle has long been a cornerstone of the EMAAR philosophy: Ideas belong to the person who is the fastest to act on them. Employees who take this principle to heart - these people are the future of the company There must be a counterbalance,if wrongly understood "Governance" can create a donkey instead of a horse as the outcome of non-effective compromises in the required decision processes. Governance carries the inside-gene for a slowdownin the speed of the decision-making processes and readiness to take on risks, in transferring of responsibilities from department to department, from working table to working table, into loss of the ability to recognize and to be aware of personal responsibility. Do not accept the waste….( also an EMAAR message ) ….of time, money, human resources……

16. Is Healthcare a Burning Platform for Change? How?

17. Traditional Health Care Episodic Requires patient initiation Not well coordinated (patients & doctors) Sporadic communication among clinicians Sporadic patient education Variable process of care; gaps in standards & guidelines Clinicians’ (personal) opinions drive decisions Systems do not prevent errors Outcomes not measured Expensive; not effective (risky for banks & investors) Badly managed, waste of time, money & motions Variability of utilisation days, costive investments (OR/ICU) Stress of overwork; shortage of qualified staff Financial pressures (troubled state economy, healthcare costs burden employers) Burning Platform for Change?

18. The problems are known; but so are the solutions: Investment is needed in: human capital (medical & managerial) regional provider structures specialised medical facilities controlled and internationally accredited medical standards & guidelines medical research & development medical education & CME international cooperation strategic partners Where & how do we want to proceed? • A targeted, process & performance focused, straight forward approach: LEAN MANAGEMENT

19. Change is needed to begin to identify VALUES • Specify “value” from the patients perspective (A quick, effective clinic visit) • Identify the “value stream” for each planned clinical outcome (product) (Request > appointment > arrival > see doctor > check-out)and remove the waste(Time on hold, callbacks, walking, wrong/unnecessary drug/test) • Make and ensure that values areflowing without interruptions from beginning to end (Staff and patients move continuously from check-in to exit; No waiting room, no staff waiting; Errors surface immediately) • Let the patient pull value from our process (Pull the appointment or med refill when you want it) • Pursue perfectionas key values(Every day, every clerk, doctor, nurse thinks about how to redesign work to improve value to the customer, and ease for us) Value is determined by the customer…not the provider!

20. Eight Forms of Waste in Healthcare • Overproduction and Production of Unwanted Products: Any healthcare service that does not add value to the patient ; Antibiotics for respiratory infections; CT screening for coronary disease with no symptoms • Material Movement: Moving patients, meds, specimens, samples, equipment • Worker Motion: Searching for patients, meds, charts, supplies, paperwork; Long clinic halls; No printer in exam room for prescriptions, patient education • Waiting: ER staff waiting for admission can’t see the next patient; Waiting for test results, records, information; Nurse waits for med, blood draw, transport, OR cleaning • Over-processing: Bed moves, retesting, repeat paperwork, repeat registration, multiple consent forms, logging requests • Inventory: Bed assignments, pharmacy stock, lab supplies, specimens awaiting analysis; Patient waiting for anything – tests, visits, discharge, phone cues • Correction of defects: Medication errors, wrong patient, wrong procedure, missing or incomplete information, blood re-draws, misdirected results, wrong bills • Wasted creativity of employees: Resident trying to find a Livonia infusion center

21. “Lean thinking”– from the overall approach to customer value • “Lean” does not mean “cheap”; lean means to focus on the production and distribution of the kind of services which have “real value” for the customer. Everything else has to be identified and eliminated as WASTE. • In Healthcare it refers to establishing a strong focus on: • Healthy environment & lifestyle • Preventive medicine • Centre of Excellence for Medical Diagnostics • Curative Medicine: Quick – Competent – Controlled Elimination of tests, treatments, steps, processes, duplications and repetitions that do not add value; Appropriateness – key dimension of quality in health care! • Medical & Social Rehabilitation • IT supported decision processes in medicine and management If its not worth doing, its not worth doing well.

22. Barbara Sweeney, RN, operating room clinical advisor, was surprised to learn that it took 57 steps in the central processing department (CPD) to prepare an operating room case cart with supplies for patients’ procedures. “I never considered looking at each step. I was focused on the end result” she recalls. Today, the same process takes 24 steps – a 58 percent reduction – thanks to some collective “lean thinking” by staff. Lean thinking at BIDMC is the product of the Lean Pilot Program begun last September to give employees tools to increase productivity, efficiency, and employee and patient satisfaction. Best practice….

23. Categorisation of Waste in Healthcare REQUIRED THINKING CURRENT THINKING Correction Processing 15 % TYPES OFWASTE Over Production WASTE Inventory Motion Waiting Unevenness Material Movement Staff 85 % Unreasonableness WASTE IS NOT DEFINED “Too little too late” REACTIVE improvement WASTE IS "TANGIBLE" Identifying small opportunities for change can result in BIG IMPROVEMENTS Source: GMS Training

24. Lean thinking, developed from the Toyota Production System, has been applied in many sectors to reduce waste and improve efficiency. Whilst healthcare and manufacturing are very different fields, they both require the efficient integration of people, processes and technology. The language and the sequence of changes may differ, but the Lean principles work everywhere and can significantly contribute to service transformation. Doing more with less • Improved quality and efficiency • Improved patient care and experience • Improved safety and reduced mortality • Reduced length of stay • Reduced waste • Lower costs • Reduced delays • Improved staff morale Improve efficiency, reduce waste and costs - combined with a pragmatic, common sense approach to service transformation.

25. Six Sigma & Lean Management Six Sigma is focused on reducing variation and improving process yield by following a problem-solving approach using statistical tools. Leanis primarily concerned with eliminating waste and improving flow by following the Lean principles and a defined approach to implement each of these principles.

26. Emaar Healthcare Group is guided by a vision - to become a leader in the sector by unveiling initiatives and delivering quality medical care that spearheads and supports the burgeoning healthcare industry in the region.  has a clearly defined development plan for healthcare, which involves integrating advanced medical infrastructure in all key centres and forming strategic tie-ups with renowned medical specialists to bring about and set best practice standards in all the regions it serves.  has a mission to enhance quality of life, by ensuring that integrated healthcare services of international standards are accessible and affordable to the people. It will also manage innovative initiatives that support the healthcare sector regionally and globally. Emaar Healthcare strives to achieve these ambitious goals and consequently add values to customers and shareholders. Lean Management & Strategy of Growth

27. To add value in Healthcare means Providing medical services as an integrated system of services in preventive medicine, health promoting services, curative and rehabilitative medicine Evidence based and in controlled and documented quality according to international standards In an effective managerial and structural manner such that the required investments generate an IRR which encourages further private investments in healthcare Agreement of Interests …. LEAN MANAGEMENT in clinical structures and processes is besides other industry approved management tools such as Six Sigma, an important prerequisite for improvements in such key values as Medical Quality, Economic Efficiency & Financial Profitability for both the Patients & the Shareholders of Emaar.

28. ήώδπεσ means “hospes”; it’s an old Greek word for “guest”. HOSPES has led to the term HOTEL and to HOSPITAL Emaar healthcare will serve the customers (patients) as guests Quick – Competent – Controlled Efficient, avoids wasting time, money and human resources, focused on customer expectations and follows a pragmatic, common sense approach in order to concentrate only on the essentials… “Lean” is reminding us …..

29. Centralized Administration & Management Centralized IT, LIS, RIS, PACS,MIS & HIS All patient information (records) available on the doctors screen in 30 seconds Waiting time for confirmed appointments < 10 minutes; for spontaneous visits 20 minutes; for emergency cases 150 seconds 20 appointments per physician (limited) per day Standards: Parking places/ valet parking; café / other refreshments; childcare Effects: The physicians are free of “paperwork” and have time for patients The patient is treated as a guest Both parties are satisfied How to put “lean management” into practice: Example 1 : Primary Care Clinics Arabian Ranches The Meadows The Greens

30. Example 2: Burj Dubai Medical Centre • The same as example 1, but in addition : • Advanced diagnostics, early detection, treatment and rehabilitation for outpatients • Highly qualified specialists of app. 100 branches of medicine from top international medical institutions • State-of-the-art technologies to detect disease at the earliest stages and modern methods of treatment and day surgery (including radio- surgery) • JCI accredited management with patient focused KPI’s (e.g.) • % of admitted Patients per Time Range • average waiting time < 10’ • % answered Incoming Calls within 90 sec=90% • % answered Calls / 60 secs. • % Patients postponed < 10 %

31. Example 3: Mother & Child Hospital • Part of an integrated cluster of Emaar Healthcare facilities • Medical Services & Patient reference through all levels of patient care including access to all medical data for physicians. • Regional tailored program of medical services which include: • Specialized pediatric & maternal/ fetal care • Health & beauty for women • Evidence based Gentle Medicine & Wellness • Family Medicine & Home Care Service • Mental Health & Counseling Professional “lean structured” management; Administrative processes as centralized as possible; JCI accreditation process starting from day one.

32. Centre for tertiary & quaternary care in dedicated fields, highly specialized surgery and medical rehabilitation. The centre is affiliated with other leading centres of the world in this medical specialty; previously patients needing this service were sent to Europe. Now this service will be available at the same quality but lower costs (more cost effective because no travel required) No waiting time Professional management, using centralised service functions of Emaar Healthcare Example 4: Specialty Hospital – Centre of Medical Excellence

33. Example 5: Health Care Cities Health Care city projects are currently at the master planning stage for three dedicated Emaar Community Locations in the MENA region. The master plan involves the complex vertical and horizontal integration of healthcare facilities at all levels (primary-secondary- tertiary- quaternary care) as well as complementary and supportive services, to meet carefully checked patient needs and expected market developments. The philosophy and practice of “lean management” will help to avoid ineffective structures and over supplying of capacities Are

34. Thank you so much for your attention !