“An Innovative 'Foot Pad' to improve Diabetic Health Care devised and offered by Surin Hospital
Surin Hospital

The Problem

Surin Hospital is a 664 bed public hospital in North East Thailand.

The hospital is responsible for the primary health care of an agricultural province. The main crop is rice but rubber has been recently introduced. The hospital deals with a range of patients from different social economic backgrounds.

The health care focus has changed from being focussed on infections & infectious diseases and now is concerned with behavioural issues leading to chronic diseases or conditions such as diabetes, which affects 10% of the local community. The hospital realised that the sole usage of drugs would not fully overcome diabetes and its increasing occurrence in the local community. It needed to look for an innovative solution to sit alongside the routine diabetes drug treatment.

Diabetes is worsening and has resulted in it becoming the 5th ranked chronic medical condition. Diabetes requires considerable medical attention and resource to prevent most patients receiving foot amputations. The number of patients with resultant amputations has risen from 6,000 in 2006 to 8,600 in 2009. A two year rise of 43%! As most diabetics come from the farming community this is of concern.

Clinical observations are made via preliminary diabetic neuropathy with numbness, deformity of the foot, ulcers and infections that finally result in unavoidable foot amputations.

Mindful of the worrying concerns over rises in the incidence of diabetes in the farming community, the clinicians have been working towards a solution for patients who need amputations.

Rubber is available locally and provides a cost effective solution to improve the “quality of life” for patients with chronic diabetes.

The medical team is proud to have reached the milestones set and with the successful delivery of health care the team can uphold be off “public confidence, of community praise, of international standards for quality of life & lastly create the impression of ‘people’ satisfaction.”

Conceptually the medical team is striving to treat patients with a “human touch” so that healthcare is “humanised” and continuously improves the quality of medical care.

The medical team compromises of a multi-disciplined task force to include physicians, endocrinologists, surgeons, and medical rehabilitation staff, physiotherapists, Orthosis Prosthesis, & administrators. They have all contributed their efforts to initiate an integrated holistic approach resulting in the “innovative Foot Pad for Health”…which was launched in June 2007.

At the Foot Care Clinic the medical team have put in every effort to merge their services together and provide a “one stop service centre” through the introduction of a rubber based foot pad specifically designed for individual diabetic patients requiring a reduction in weight impact and the facilitation of a blood supply to the tissue of wounds. This has resulted in less patients suffering from infectious complications. The concept of biomechanics has resulted in a reduction of pressure forces acting on the foot including the reaction of tissue. The pressure can be adjusted for each patient. The aim is to reduce the duration of severity for patients. It can be used for patients with leprosy in foot ulcers.

Solution and Key Benefits

 What is the initiative about? (the solution)
The key elements pertaining to the hospitals multifunctional staff and its supporting systems and practices are co-ordinated by the Human Resources Department, (HRD), who adopt lean practices to ensure the competency of the medical & nursing team and quality of care to create public awareness towards the benefits for diabetic patients in changing their attitude towards the use of the foot pad and medical foot care in general.

Patients are now being continuously convinced to trust the introduction of the foot pad and the benefits in reaching a total care solution resulting in the reduction of wound repetition and the expansion of quality medical treatment.

The hospitals Patient Care Team is a well organised group who have created a “one stop service” for community based practices, which province wide, caters for 32 affiliated primary community health care units which includes conducting intensive training programmes & consultative services to a wider scope, in all sectors, nationwide.

In a practical sense the hospital has successfully achieved the desired result in cost saving from the governmental budget allocation as fewer patients are experiencing extreme treatments such as foot amputation. The hospitals investment in a local solution, from the sourcing of the rubber and the manufacturing of the foot pad, is 5 times cheaper than the alternative imported version. In effect the adapted exudate suction machine is now replaced with the hospitals “state of the art” standard machine which copes admirably with the increasing demand for this type of solution owing to the growth in diabetes rates. The efficiency and quality performance has improved via this service innovation.

The hospitals “one stop service” practice has evidently made a number of processes redundant and solutions have progressed more vibrantly.

Any benefit from a medical advance must be measured against the cost of introduction, (research & development) with the reduction in individual cost per patient treatment. If the advances are too costly then regretfully they will not go forward. In this instance the foot pad has proved to be five times cheaper that the previous solution and significantly it has resulted from the engagement of the very community suffering chronic diabetic diseases…farmers, by the growth and purchase of the raw material needed for the foot pad – rubber!

Leaving aside the cost to benefit ratios, which have reduced significantly, the real benefit, must be measured in patient care and reduction in foot amputations. If the medical advance achieves all of this then it must be important to the community as a whole. In this instance the foot pad improves the patients diabetic conditions, reduces foot amputations, benefits the local framing community financially and really is a “win-win” solution for all.

Also the sense of achievement in all the stakeholders who contributed to this project cannot be overlooked. Achievement & personal recognition is one of the greatest motivators at any working environment. When you own work is recognised and has the “knock on” effect of patient benefits then the sense of achievement is somewhat greater!

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Because & through the tireless efforts of the major medical agencies / teams, and for all those who participated and contributed, the hospital has been able to get to the heart of quality improvements. Via the hospitals envisaged cultural “humanised healthcare” policy the multi tasked & talented work force has shown good discipline and they have not been found wanting in their spiritual determination to succeed and become voluntarily service minded.

Consequently, all relevant agencies, and their related activities, have been actively engaged in responding positively to the hospitals new medical innovative and they have all responded in the most positive of manners. In addition the project has achieved widespread public recognition and this is measured by increasing visits to the hospitals web site and page concerning this issue. The hospital regularly updates its website regarding this ongoing project. The public’s recognition is highlighted by the specific example of a prominent young nursing graduate, from Austria, who gave the most favourable of feedbacks. If the foot pad is being viewed internationally then the opportunities to gain a revenue source from the development increases significantly.

The hospitals own internal organisations have shown their appreciation of this “special project”. All the concerned stakeholders from clinicians, to engineers, to cost accountants and senior management are proud of their achievements leading from the development of the foot pad solution for patients with chronic diabetic diseases. Most of all the greatest stakeholder is the person or persons, (patients) who have the most to gain from improved treatment of their diabetic concerns.

In addition the hospital has been praised by networking the Hospital Accreditation Centre, (HACC), the Forum of Hospital Accreditation, (HA), and the following Thai Departments & Authorities:-

• The Department of Health
• The Office of the Permanent Secretariat
• The Ministry of Public Health
• Community Hospitals
• Provincial Hospitals
• The Provincial Administration Organisation
• Local Administrative Organisations
• National Health Security Office, (NHSO.)
• The General Hospital Society

In addition the hospital has been praised from:-

• The Thai Association of Diabetic Educators, (1988.)
• The Endocrine Society of Thailand
• The Physical Therapy Association
• The Foundation for the Development of Diabetic Care

More importantly the recognition from the hospitals own patients have driven the team to work harder towards providing a better quality of service to diabetic patients. The Foundation for the Development of Diabetic Care, a well respected international organisation, has encouraged the hospital greatly.

Finally, the outsourcing shoe designer corporation had added value to the project by producing visually attractive footwear that is not only trendy and fashionable but achieves dignity for the patients. The product achieves a sense of normality for all valued patients!

A large number of the hospitals chronic diabetic sufferers come from the local, poor farming community and by selling their raw materials to the hospital, rubber, they have a duel stake in this venture as a patient but now as a seller of a cash crop – rubber.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main strategy was developed via the encouragement & determination of the Chief Executive Officer, (CEO) of the hospital. There was clearly a clinical need to cope with the increasing burden of rapid rises in chronic diabetes in the local community. This “lifestyle” development of diabetes lead the clinical management team to seek the assistance of the hospitals entire team of professionals to seek solutions to the cases of clinical foot amputations and how a solution could be found to reduce the number of “final straw” solutions – amputations.

It was the CEO’s responsibility to formulate a strategy to assist the core need to assist patients but also reduce the burden that the rises in diabetes patient care costs incurred. The main strategy revolved around two key issues. First “how could the hospital cope with the rise in cases of chronic diabetes and foot amputations?” and secondly, “how could the hospital reduce the cost of individual care per patient?”

With a limited and fixed budget set and the situation where cases of chronic cases of diabetes was rising, (almost out of control), the hospital needed to sit down with all concern health care professionals and seek a solution to its core strategy of reducing foot amputations and reducing costs per patient cared for.

The clinical team & administrators of the hospital then met over many months to decide the fundamentals of any strategy:-

• What is the need & why is it needed.
• What is the process improvement or manufacturing need to manage the “what & why.”
• What is the cost to benefit ratios?
• Who will benefit and what impact will improvements have on the quality of their life style or prolong their life?
• How will initiatives be introduced, when & by whom?
• Will the new process or initiative be better than the old / current solution and will it be fully affordable?
• Will it save the hospital money and reduce the impact of a rise in chronic diabetes on the hospitals budget?
• How can the costs be controlled and the cost to benefits ratios is measured?
• Is the investment in time and staff resources likely to positively improve patient care and discover a new procedure that would benefit all stakeholders?

The hospital had a third “knock on” strategy of how any technological advances could be used to fight other patient care issues such as hypertension, kidney related issues and the care of the elderly.

The CEO drew all stakeholders together to see a solution and achievement of its 3 core strategies. This involved co-ordination of the Patient Care Team, all Clinicians, Engineers, and Accountants who would be involved in budgeting and estimating / controlling of the procurement process. The development and implementation of the hospitals strategy will be covered in sections 4b – 4c.

So, in summary, the whole hospital team was responsible for the strategy and they set the objectives and initiatives needed to succeed.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The key development was the introduction of the “Foot Pad.”

The strategy and need is outlined in section 4a. With a rise in chronic diabetes and foot amputations a solution was needed “so as” to improve the quality of patient care, cope with rising diabetes patient care costs and better the former solution of the Exudate suction machine.

The first stage involved looking for an alternative solution. The cost of this solution was prohibitive. Clinicians and engineers look for an alternative solution jointly. Through the resources of the physicians, endocrinologists, surgeons, medical rehabilitation staff, physiotherapists, Orthosis Prosthesis, & via the application of biomechanics the hospital was able to conceptually arrive at the solution – the Foot Pad.

Once the solutions conception was arrived at the administrative team then focussed on where to source the raw material needed. In this instance, rubber, which was readily available locally in Surin Province as rubber was a recently introduced cash crop locally. By sourcing the raw materially locally it would benefit the main group of chronic diabetes sufferers…farmers!

As the raw material was available locally its cost would be much lower as it could be purchased directly from the farmer himself, it would incur hardly any transportation costs and its supply would be guaranteed.

The next stage involved the development of machinery necessary to produce the form needed for the biomechanical solution arrived at. Local engineers arrived at a simple suction machine which vacuums the air via a suction process aided by a waste / trash bag.

Clinicians were then involved in taking the next stage forward…the fitment of the foot pads to the patient. Footwear designers were involved to reach a visually appealing final product.

Clinical trials then took place to establish the benefit of the new technological development when compared to the educate suction solution. Once completed, and the cost to benefit ratios established, then general introduction processes took place. This involved the manufacture of foot pads tailored to the patients individual needs, training of all concerned health professionals and a Public Relations exercise to get patient “buy in” to this new advance. Finally, once established a real benefit to patients and cost saving was arrived at a general “roll out” to other health institutions in Thailand took place.

The process of developing the foot pad has been streamlined to include:-

• The new form pump produces the necessary raw material – rubber.
• A casting is taken from the patient and set in plaster of Paris.
• The rubber is moulded from the cast.
• Adjustments are made for the individual patient’s foot requirement.
• The machinery has been developed to incorporate a simple suction machine which vacuums the air via a suction process aided by a waste / trash bag which enables individual adjustment of the foot pad to fit the patient’s foot accordingly.
• The new solution enables the hospital to embrace the 4 dimensions of medical care & fundamentals:-

1. Promotion
2. Prevention
3. Treatment
4. Rehabilitation

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
When an organisation is faced with rising clinical costs, an expensive solution, (the exudate suction pump) and set budgets, the obstacles encountered are likely to be many.

When a solution involves micromechanics and clinicians, without the benefit of a well funded research department, then the need to work as a joint development team is paramount.

In essence there were several key obstacles:-

1. To get the entire hospital team to work as if “one unit” and ensure that the project was co-ordinated by a central person…the CEO.
2. Overcome technical and clinical obstacles.
3. Reach a cost effective solution.

The CEO co-ordinated many meeting to establish conceptual clinical solutions and technological developments that would benefit all stakeholders. Individuals then had to “come up with the result.” They did so by working tirelessly towards a solution than made each stakeholder see the “bigger picture” and to become completely focussed on the end result…a reduction in foot amputations, better patient care and a substantial cost saving.

Through the dedication of its multi skilled staff the hospital overcame all the internal obstacles needed for the project to succeed. It had arrived at a clinical solution that overcame both the manufacturing, clinical and cost obstacles.

The hospital faced one last obstacle.

Initially patients were not convinced or motivated by the new approach. This was an obstacle that the hospital had to overcome.

The hospital tried & succeeded in putting processes and structures in place to win the confidence of all stakeholders… the hospitals staff, management and most importantly the patients themselves. All stakeholders were empowered to equip themselves with all necessary means required to make the project a success.

The hospital incorporated a Public Relations exercise, (PR) which included posters, brochures, handouts and finally promoting health care education via local Community Radio facilities. This holistic humanised health care approach has retained and created a self help programme for patients to “buy into” their own health care issues which has kept “on-board” the physical, emotional, social & spiritual structure of patient care. The hospital has been fortunate when following through its primary prevention measures and been able to embrace the 4 dimensions of medical fundamentals offered to its mainly improvised agricultural and poorly educated patients that are found in the hospitals catchment area.

In relative terms the hospitals resources were limited but thankfully the project has prospered because of the creative development of the foot pad solution via its dedicated and hardworking teams and staff.

The hospital is grateful that the innovative solutions have not only saved the hospital a great deal of money, reduced its cost base, but more importantly it has benefited the direct needs of the local community. The hospital has demonstrated good governance with its transparent procurement policies with well planned cost effective procedures. The investment in this project enables the hospital to regenerate income in return. Also the purchasing of local raw materials, rubber, via the local farming community, benefits all persons either directly or indirectly within the Surin area.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Most clinical developments or advances take place, not by pure inspiration, but by dedicated and expensive scientific research.

Being a rural provincial hospital, Surin Hospital did not have the benefit of a fully funded & functioning Research & Development Department, (R & D.) The hospital is based in a rural province in Thailand where its patient catchment area is drawn from mainly an agricultural impoverished patient base where money is scarce. Research is expensive. Taking a development to implementation stage is also expensive. R & D was a resource that the hospital just did not have access to!

The hospital was faced with a dilemma. The rise in chronic cases of diabetes and foot amputations demanded a local solution. Its only resource was the hospital clinicians, health care professions, general administrative staff and patients to work with.

The hospital resources, its staff, needed to devise an effective treatment and devise development that could be used in the prevention, treatment, diagnosis and symptom relief for acute diabetes and resultant foot amputations.

The main need was to develop a cost effective alternative solution to the Exudate Suction pump. The resources available needed to concentrate on the creative work necessary in a systematic basis to increase its stock knowledge to devise new solutions and applications. It also needed help from outside resources to include engineers, micromechanical professionals, farmers to grow the raw material, (rubber) and accountants to measure the benefit to cost ratios.
It was the CEO’s responsibility to co-ordinate the resources available – the hospitals own staff and outside contractors / engineers.
Many meetings, both at executive and clinical levels were held. The first stage was to marshal the resources, the hospitals staff, to propose clinical solutions. Once proposed the team of accountants then measured the likely R & D costs. It was necessary to procure local grown rubber, develop a machine to mould a foot pad and then bring the foot pad solution to the testing, evaluation and implementation stage. Accountants then had to measure the cost of development, (the R & D) to the cost savings in so far as the cost of diabetes treatment unit costs per patient and to then compare these costs against those of the Exudate Suction pumps.
The team quickly established that the foot pad solution was very cost effective. It proved to be 5 times cheaper than that of the imported solution. The Simple Vacuum pump was more effective than the Exudate Suction pump and the clinical benefits would result in a reduction in foot amputations. In effect it was a “win- win” solution. The winners were the patients, the Patient Care Team, the hospital clinicians and the budgetary control team – the accountants. Everybody gained something.
Measuring the limited resource, the benefits of the foot pad solution and improvement in patient care with the cost savings it is clear that the hospital made full use of the resource available.
From its inception in June 2007 to date the foot pad has come a long way!

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The medical team has been fully determined to improve the quality of its primary health care to diabetic patients and adjust to the upward trend in the incidence of diabetes in the general population. This humanised health care service has greatly benefitted from the introduction of the foot pad procedure and manufacture and has been a most positive and innovative step towards coping with the increasing cases of chronic diabetes.

The foot pad solution has proved a good alternative to those high risk diabetic patients. All stakeholders are pleased with the outcome of this innovative treatment method and all have shared the same ethical mindset which has been paralleled with seamless co-operation between each other and the hospitals school of medical professionals. This proactive approach has lead to a sense of responsibility, recognition and professional rewards amongst all stakeholders.

The Foot Care (Case) Management Centre has administered its clinical outreach in shifting emphasis to create a focal point to monitor irregularity in pathology whilst observing the early detection of diabetes via its capable Patient Care Teams. It has become the social norm that the team and its patients work with diabetic issues in environmentally friendly surroundings coupled with public awareness of the hospitals well recognised logistical setup and financial stability; through good governance of its budgets and accounting practices employed by the hospitals administrative support teams.

Nearly all of the hospitals patients are financially assisted via the support offered by the National Health Security Office which provides refunds of health care expenses. This allows and provides “treatment to all persons with diabetes.” The hospitals case management teams liaise fully with the hospitals networked affiliated health outlets and this provides patients with a readily accessible solution to their primary care needs.

The programme allows for:-

1. Clearly defined policies and procedures to allow for a seamless system of user friendly health care solutions with regard to the needs of the diabetic patients.
2. The engagement of the local farming community via the growth and subsequent purchase of rubber for the manufacture of the foot pad.
3. The cost of patient care is greatly reduced by the introduction of the foot pad which is 5 times cheaper than that of the alternative method of treatment. The foot pad prevents or limits foot amputations.
4. Provides for the transfer of technology and training to include hospital staff and the hospital affiliated health care outlets. This transfer of technology and training reaches over 20 health care organisations to include the local community and its Ampurs and provincial outlets. The hospital also offers assistance to hospitals nationally and it’s consulting professionals. The training is well organised and regular in nature. This provides a constant improvement in health care to patients and widens the experience and skill levels of the health professionals.
5. A proactive support service that offers the community and provides for an expanding network of open teaching, without charge, to public health personnel in many community hospitals with the Surin Area.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The main lesson learnt was that by adjusting to the increasing needs of a rising diabetic patient base within the Surin Area the hospital was able to provide the general public with a more cost effective solution via a local sourced product, rubber, and the manufacture of a solution, the foot pad, which lead to better treatment of diabetic patients.

The hospital learnt that the continued use of an expensive alternative treatment to the new foot pad was not “good practice” and that hospital staff needed to find a more cost effective solution that benefitted the community as a whole.

The old fashioned treatment methods were urgently in need of reform via continuous process improvement in its practices and procedures and if not improved then the hospital would provide a poorer level of primary health care to its patients.

Given the hard working nature of the health care professionals at the hospital they were all able to come together as a group and provide its patients with a better solution to its diabetic needs, the foot pad, and that there was a need for the hospital, its staff and patients to work together to find solutions and levels of care that all stakeholders embraced.

That the model of working seamlessly together, as all stakeholders did in the Foot Pad programme, was easily transferrable to the heath care needs of other patients such as the elderly, the disabled and to the Non Communicable Disease Section, (NCD), and as such the hospital is actively working towards other solutions to increase the health care offered to the public.

Equally the hospital is resolved to learn the lesson that PCT, or The Patient Care Team, can provide the solutions necessary to improve its primary health care systems and services. It, the hospital, also learnt that by utilising its multi disciplined task force & embracing teamwork that solutions were readily on hand allowing for:-

• Cost effective solutions.
• The saving of money which can be re-invested and thus provide an income stream at a later date.
• That the local community can benefit by farming rubber which can then enrich the lives of diabetic sufferers.
• That the Foot Pad can be “rolled out” nationally and that the hospital can offer and co-operate with other health service providers nationally.
• That the concept of neighbourhood environmental and adaptive techniques can humanise its health care systems and provide sustainable solutions going forward.
• That the basic concept that rubber is sticky, thick, readily available locally, that soft form can easily be formed and that the locally, sustainable crop, (rubber) can be utilised to manufacture a solution, the Foot Pad, that improves patient treatments and benefits the community as a whole and is very much cheaper that the previously used alternatives. The “end product”, the Foot Pad, is more advanced and adjustable and provides a better treatment route to follow.


1. The Foot Pad provides a more effective diabetic treatment.
2. The Foot Pad can be manufactured under the hospitals complete control and is 5 times cheaper than the alternative solution.
3. That the manufacture of the Foot Pad uses locally, fully sustainable materials – Rubber and that benefits the local farming community.
4. That the hospital has developed a holistic humanised patient care process.
5. That the multi skilled team at Surin Hospital has developed the solution themselves to the benefit of all stakeholders.
6. That the Foot Pad can be introduced more widely locally and “rolled out” nationally.
7. That training will improve the skill set of the health care professionals within the Surin and surrounding areas.

Contact Information

Institution Name:   Surin Hospital
Institution Type:   Government Agency  
Contact Person:   Mr.Thongchai Triviboonvanich
Title:   Director of Surin Hospital  
Telephone/ Fax:   +(66) 87 439 3776
Institution's / Project's Website:   +(66) 44 514 127
E-mail:   sk_map@yahoo.com  
Address:   68 Lukmuang Road
Postal Code:   32000
City:   -
State/Province:   Surin
Country:   Thailand

          Go Back

Print friendly Page