Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694824614227.pdf (Georgia)
Clinical strategy and performance overview Speaker: Gia Khurtsidze, Chief Clinical Officer GHG Investor Day Tbilisi, Georgia | 23 November 2016 www.ghg.com.ge Where we stand now and where are we going Our main challenges Our goals (medium term) Lack of doctors & Nurses: quality and new generation Quality of basic medical care XX XX XX Knowledge and expertise advancement of our physicians and nurses through education and practical development Develop and implement quality management measures at a larger scale within our healthcare facilities    Lack of services Strengthen existing services and launch new ones 2 It is the first class leaders of our medical team that are driving the improvement of service quality and access to healthcare across the organisation Our clinical team GHG Clinical department GREGORY (GIA) KHURTSIDZE Saint John Hospital, North West Kaiser Permanente Division, Longview, WA and Huron Hospital, Cleveland, OH CLINICAL QUALITY MOTHER AND CHILD HEALTH PEDIATRIC CARDIAC SURGERY NINO BUTSKHRIKIDZE Tbilisi Central University Hospital, was the emergency the coordinator of medicine project in Georgia DAVID TSIBADZE Jeanne de Flandre Hospital of Lille, Timone Marseille University Hospital, Purpan-Toulouse Paediatric Hospital Network in France POSTGRADUATE EDUCATION EKA SEPERTELADZE Georgia Ministry of Labor, Health and Social Affairs, Head of Accreditation Department for postgraduate educational programs NURSING DEPARTMENT TAMAR DOWSE Princess Margaret hospital, Cardinal Health of Swindon, Project Officer at Salvation Army (all in the UK).
PAATA KALANDADZE Policlinico di Monza and Papa Giovani in Italy, Alder Hey XXIII hospital in Liverpool and Children’s Hospital in the Royal Children’s Hospital Melbourne CARDIAC SURGERY ZAZA KATSITADZE the University Hospital in Switzerland, the Regional Hospital in Tallinn, Estonia, the University Hospital of Geneva in Switzerland INTERNAL MEDICINE SURGICAL CRITICAL CARE MARIKA TOIDZE Milan University Hospital, Weill Medical College of Cornell University in New York Presbyterian Hospital Position is vacant LEVAN SUKHISHVILI Schuchtermann Klinik in Germany, Jo Ann Medical Centre and Regional Hospital Sachkhere in Georgia LABORATORY PATHOLOGY ONCOLOGY NINO ABESADZE University Medical Centre Hamburg Eppendorf, Oncology and Hematology department for children ALEXI BAIDOSHVILI VU Medical Centre in Amsterdam, President of International Academy of Pathology Georgian Division (IAP GD KOBA KIKNAVELIDZE The University Hospital of Mannheim in Germany.
Scholar of the European Association of Urology 3 We are growing a new generation of doctors & nurses Challenge What we are doing Lack of doctors & Nurses: quality and new generation 1 GHG Residency Programs Doctors:  High number of doctors with Soviet education  Average age c.50  Shortage in number of specialties Nurses:  The WHO recommends a nurse to doctor ratio of 4:1 for Georgia  Current ration of 0.9  Evidence based medicine and western standards of care is  our baseline In 2016, launched residency programs in 20 specialties (Pediatric Neurology, Pediatric Emergency Medicine, OBGYN, Anesthesia/Critical Care, Pediatrics, Pediatric gastroenterology, Neonatology, Pediatric Cardiology, Laboratory Medicine, Internal Medicine, Endocrinology, Pediatric Endocrinology and Radiology, General Surgery, Orthopedic Surgery, Neurosurgery, Pediatric General Surgery, Oncology, Radiation Oncology, Cardiac surgery - pending)  With total residency quotas of 243  58 residents enrolled currently  110 vacant positions will be announced in December  It takes on average 33 months to complete the residency program  Sourcing and expertise advancement of our physicians and nurses through education and practical development 4 We are growing a new generation of doctors & nurses Challenge What we are doing Lack of doctors & Nurses: quality and new generation 2 GHG Doctor Retraining Programs 2016 Doctors:  High number of doctors with Soviet education  Average age c.50  Shortage in number of specialties Nurses:  The WHO recommends a nurse to doctor ratio of 4:1 for Georgia  Current ration of 0.9  1842 doctors in four specialties (OBGYN, pediatrics, internal medicine, Laboratory) and ten programs  2098 nurses retrained (Anatomy, Physiology, Medical calculation, procedures.)
Category Jan-Dec, 2015 Jan-Sep, 2016 NURSE DOCTOR Total Number Of Trainees 1960 1720 3680 2098 1842 3940  Sourcing and expertise advancement of our physicians and nurses through education and practical development 5 We are growing a new generation of doctors & nurses Challenge What we are doing Lack of doctors & Nurses: quality and new generation 3 GHG Trainers of Trainers Program (ToT) Doctors:  High number of doctors with Soviet education  Average age c.50  Shortage in number of specialties Nurses:  The WHO recommends a nurse to doctor ratio of 4:1 for Georgia  Current ration of 0.9  In 2016, 80 of our employees completed Trainers of Trainers programs in these specialties:  Nursing General  Nursing Operational  Basics of Pediatric Critical Care  General Critical Care Basics  Sourcing and expertise advancement of our physicians and nurses through education and practical development 6 We are growing a new generation of doctors & nurses Challenge What we are doing Lack of doctors & Nurses: quality and new generation 4 GHG Continuous Medical Education (CME) Doctors: Despite the high number of doctors available in Georgia, the average age of our doctors is c.50, they mostly come with Soviet medical education and we have a shortage of doctors in a number of areas.
Nurses: The World Health Organisation recommends a nurse to doctor ratio of 4:1 for Georgia, compared to our current ration of 0.9 nurses per doctor.
 2014-2016 - we focused on building continuous medical education platform in five specialties:  OBGYN  Pediatrics  Internal Medicine  Lab  Nurses  14 CME programs conducted  630 doctors and 3327 nurses engaged during three year period  Sourcing and expertise advancement of our physicians and nurses through education and practical development 7 We build robust clinical quality management processes Challenge What we are doing Lack of clinical quality management practices on national level  Quality Management since the Soviet era still in the early state of development  No official / comprehensive framework of protocols or treatment guideline available on National level 1 GHG clinical quality framework development 2015-2018 Goals:  Risk management  Safety  Infectious control Strategy:  Building quality database  Training professionals in the area of clinical quality  Develop and implement quality management measures at a larger scale within our healthcare facilities 8 We build robust clinical quality management processes Challenge What we are doing Lack of clinical quality management practices on national level  Quality Management since the Soviet era still in the early state of development  No official / comprehensive framework of protocols or treatment guideline available on National level 2 GHG Clinical Quality Trainings  2015-2016 – Implementation of Clinical quality management framework  18 trainings in quality management topics around infectious control, database management and KPIs completed  2 trainings ongoing  43 training courses planed through 2018  Develop and implement quality management measures at a larger scale within our healthcare facilities 9 We build robust clinical quality management processes Challenge What we are doing Lack of clinical quality management practices on national level  Quality Management since the Soviet era still in the early state of development  No official / comprehensive framework of protocols or treatment guideline available on National level 3
 GHG Clinical Quality Protocols  Internal process of development and implementation of protocols lunched  Evidence based medicine and western standards of care as a baseline for  Clinical protocols  Nursing protocols  Hospital performance SOPs  Quality and safety policies    129 protocols are approved 40 are in progress 130 are planned  Develop and implement quality management measures at a larger scale within our healthcare facilities 10 We build robust clinical quality management processes Challenge What we are doing Lack of clinical quality management practices on national level  Quality Management since the Soviet era still in the early state of development  No official / comprehensive framework of protocols or treatment guideline available on National level 4 GHG Clinical Quality Monitoring  2016 - Clinical KPI monitoring implemented in 16 hospitals  Ongoing in 10 hospitals (expected to be completed - 2017)  Develop and implement quality management measures at a larger scale within our healthcare facilities 11 OUTPATIENT CARE Outpatient encounters in Georgia are low at 3.5 a year, compared to the CIS average of 8.9 and European Region countries of 7.5, according to WHO LABORATORY SERVICES  Number of lab tests are still sent to the laboratories abroad.
 Pathology service is outdated and 30 years behind European level CANCER  Very low reported incidence levels  Malignant neoplasms incidence rate in Georgia is 140.3, compared to 543.7 in EU, and the detection of over 30% of malignant neoplasms occur at stage IV MATERNITY CARE  Highest number of caesarean among the former Soviet Union republics – 39% of the total number of all deliveries in 2014.

 Maternal mortality ratio per live births three-times higher in Georgia than in the European Region.
EMERGENCY CARE  Emergency units simply did not exist in Georgia until several years ago.

 hospitals had to staff emergency units with over 15 different specialists, which decreased the quality and efficiency of the ER Service gaps in Georgia NEONATOLOGY neonatal mortality was 60-80% of under five mortality during previous years, well above the 43% global average.
PEDIATRICS  Biggest share in medical services import is The culture of regular visits to the doctor at an early pediatric age - as a favorable heritage from Soviet-times PEDIATRIC CARDIO SURGERY For almost 15 years, there was only one center in Georgia that provided cardiology and cardiosurgery services for children.

CARDIOLOGY  hospitalization rate per 100,000 population that was 1,647 in 2014, which is two-fold less than in CIS and European Union countries.
 cardiovascular diseases represent 16.5% of deaths CRITICAL CARE  The lack of quality of care in a number of areas in the Georgian healthcare system puts strain on critical care units 12 We fill healthcare service gaps in Georgia We launched pediatric cardio surgery Was We achieved Our plans Only one center in Georgia  Launched service in August 2015     Initiated with multi national cardio surgical teams (Italy, Germany, China, Israel) with hands on training for local team 53 surgeries – at average revenue of GEL 15,000 Strong service quality, with low lethality (2) Since October 2016 the local team performs surgeries  Targeting - 250 surgeries per year  Cardiac Surgery residency  To have complete Georgian team performing surgeries  Strengthen existing services and launch new ones 13 Picture 1: Liver transplant patients at GHG Picture 2: Liver transplant patients at GHG 14 We fill healthcare service gaps in Georgia We launched liver transplantation Was We achieved Only 2 centers in Georgia with successful cases  Launched service in December 2014  Assisted by multi national cardio surgical teams (Italy and India) providing practical training to local team  Completed 9 successful surgeries at average revenue of GEL 125,000  Excellent performance record - 0 lethality Our plans  Expanding the department, targeting 20 surgeries per year  Consolidate transplant program (Liver, Kidney – pediatric and adult) in Tbilisi  Start transplant residency  Have local team perform surgeries independently in 2017  Strengthen existing services and launch new ones 15 We fill healthcare service gaps in Georgia We launched oncology center Was We achieved Suboptimal due to outdated technology Soviet era staff with poor access to new western standards of care Significant outflow of patients abroad  Launched service in July 2015   In 2015 serviced over 165 patients - at average service revenue of GEL 5,000 2016 - so far 700 patients treated  Target - 2000 per year   Staff reinforced with Georgian repatriate physician team practicing in the Europe for 2 decades Standard of care is approaching European guidelines Our plans  Second linear accelerator in Kutaisi  Expansion of existing unit (it has capacity to double the flow)  Hematology unit up and running for BMT  Development of Pediatric Hemato- Oncology  Strengthen existing services and launch new ones 16 Where we stand now and where are we going Our main challenges What we achieved Goal XX XX XX Lack of doctors & Nurses: quality and new generation Quality of basic medical care Lack of services     3500 doc’s /4000 nurses retrained  80 ToTs developed  243 residents in 20 specialties Complete first round of stuff retraining by 2020 Quality control framework development initiated Over 10 new services introduced Over 50 service departments expanded or established at new locations Complete quality management framework implementation.
Receive JCI accreditation on 4 of our locations by 2020 Continue to launch new services Capture patient flow export.

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GHG Investor Day Tbilisi, Georgia | 23 November 2016 www.ghg.com.ge Disclaimer This presentation contains forward-looking statements that are based on current beliefs or expectations, as well as assumptions about future events.

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