Questions/Answers

Feet are the important part of the body. The feet hold the whole-body weight. Foot structure abnormalities or long hours of weight bearing activities during the day could cause foot pain. According to Thomas et al(1) 39% of population have a foot problem that might disturb activities in their daily lives. Some foot problems may cause a devastating complication. For example, chronic diabetic foot ulcer could lead to amputation and disability. Moreover, Levelille et al, noted that foot pain truly affects capability in everyday life of female elderly.(2) Thus, healthy feet would definitely lead to good physical health. Benvenuti et al claimed that a proper assessment and treatment of foot problems could help prevent a foot injury and decrease disability.(3) Foot health has a great impact on people’s health. Lack of knowledge and inaccessibility to foot health checkup can cause serious problems. Therefore, foot health problems affect people at the national level. In Thailand, most patients received services when a foot injury affects daily lives, causing a loss of time and expense. Foot orthoses (FO) can prevent and decrease pain. This treatment uses the principle of correcting foot deformities, distributing weight, reducing heel shock, friction, and increasing comfort. FO for medical treatment is produced by a professional orthotist. This is a standardized treatment approach and can reduce the cost of surgical treatment by up to 200 times.(4) The custom foot orthoses are recognized as a treatment that prevents foot injuries and treats foot diseases such as bruises, flat feet, deformed feet, and diabetic feet.(5-7) Foot care is a multidisciplinary team effort. In the past, Thailand had very few orthotists who specialized in foot health. Many hospitals have a shortage of specialists and insufficient tools and equipment leading to long waiting time to receive foot orthoses.

“Innovative Foot Orthotic Clinic '' is an innovative service to increase access to foot health care service and is the first one-stop service in Thailand. It provides foot care and responds to individual foot problems at professional standard quality.Technology is applied to improve diagnostic precision and reduce production time and process to enable fast services. The innovation creates cooperation among multidisciplinary teams. The clinic environment is renovated for client’s convenience. Patient’s opinion is welcomed for the continual development process and to enable the rights to access to care for all.

The initiation aligns with the third goal, "Good health and well-being" as it covers the whole dimensions of health promotion, prevention, treatment, and rehabilitation. The clinic provides knowledge on foot care such as selecting suitable shoes for each foot structure. It enables patients to receive appropriate and comprehensive services that are suitable to each patient's condition and needs following professional standards. It also helps prevent, reduce, and slow deterioration of severe injuries that may result in disability which creates long-term healthcare costs. It also supports Goal 10 in reducing inequalities. The clinic provides services for all genders and age groups, focusing on responding to patient problems and needs for foot health care, especially for those who have injuries or problems with foot health, and people with disabilities. Moreover, the services enclose all rights to treatment without the extra cost.

Foot care in Thailand is not a widespread health service. People have insufficient awareness of foot health. Therefore, promoting foot care education is an important measure for behavioral change. As the first model clinic in the country, the key success is transferred to our networks and alliances both in academic institute and general hospitals. The clinic is used as a platform for knowledge transfer by exchanging the students, on-site training, and sharing in the academic conferences.

The development of the “Innovative Foot Orthotic Clinic (IFOC)” is an innovation of specialized services that increases access to government services at affordable cost. It serves people with all foot diseases such as foot abnormalities, diabetic feet, and foot pain. The cornerstone in developing the clinic is the patient-centered care. The new technology has been implemented to assist in the patient assessment process to analyze the problems, make an accurate diagnosis, and enhance the production of Foot Orthoses(FOs) within shorter period of time with the standard quality. Therefore, IFOC is outstanding and different in terms of uncomplicated service systems with customized FOs according to the individual problem. FOs is accepted as a conservative treatment that prevents foot injuries and foot diseases such as plantar fasciitis, flat feet, deformed feet, diabetic feet, and also decreases the severity of diseases. The clinic covers all foot diseases starting from birth to complicated diseases. The fast and easy system makes it convenient for all patients to receive a premier service and devices without extra-cost and reducing unnecessary waiting and traveling time and expenses.

Innovative Foot Orthotic Clinic promotes foot healthcare services for all ages without distinction between gender and social status. The implemented technology making the Foot orthosis possible to fit in all shoe types, including high heels, eliminating the gender barrier. The cost of treatment is covered by every medical benefit scheme in the country without extra cost.

Innovative Foot Orthotic Clinic provides services for all foot diseases. The continuous improvement process is applied to meet patient satisfaction. Modern technologies have been implemented in the clinic to enhance effective assessment and reduced the production process. The conventional production time takes 5-7 days to manufacture a pair of insoles while with applied modern technologies the time is cut down to 1 hour. Therefore, the clinic can serve more patients every year (shown in the graph attached, however due to the pandemic of COVID-19, the number of patients decreases in 2020-2021). Moreover, in order to support the growing demand of patients, staff skills and expertise need to be continuously developed. Health literacy is another mission of the clinic. The information about foot and related topics has been promoted through communication channels in various formats such as website, Facebook, YouTube, Line application, and public relations media. The clinic is a service model that both government and private agencies are interested in in order to transfer knowledge for further development.

The development approach of the Innovative Foot Orthotic Clinic is as followed. 1.The first priority is to develop capable personnel. This includes planning, allocating, and increasing the number of specialized personnel by attending training in Thailand and other countries. The knowledge is shared among orthotists within the organization to promote community of practice. 2.The service system is then improved by readjusting the procedures, simplifying workflows, and increasing service effectiveness with cooperation of a multidisciplinary team, such as rehabilitation doctors, physical therapists, andorthotists. The clinic reduces the whole process into 1 day instead of 5-7 days by the implementation of the modern technologies. Moreover, the clinic establishes the follow-up system in every patient to ensure quality of use. 3.Advanced technology is introduced into the assessment and manufacturing of insoles, for example, designing insoles by CAD-CAM, which is a computer system that helps to collect data from foot scanning, design insole shapes, and manufacture insoles within 15-20 minutes. The patient’s data is also stored and can be accessed at any time in order to duplicate the device. This technology can manufacture four insoles in less than an hour. Besides, the foot scanner is portable, hence, it can be used to serve people at the mobile clinic. 4.The clinic environment is renovated in order to serve more clients at the same time.

1.The inadequacy of the staff is planned to be solved by encouraging the knowledge transfer within the organization. 2.The waste time in appointment process is managed by leaning the system, for example, using the phone appointment in order to lessen the time spent at the unit. 3.The general population’s health literacy on foot care is still quite low. They tend to access for service at the very late stage, making the foot problem more complicated, creating higher cost of care and poor outcome. Thus, this program also offers the foot health knowledge for general public.

The foot pressure scanning technology has been implemented in the Innovative Foot Orthotic Clinic to enhance the efficacy of foot assessment for individuals. The static and dynamic foot pressure will be analyzed individually and used in the designing process to improve device quality. Moreover, the CAD/CAM manufacturing technology has been utilized to simplify workflow and increase device quantity and quality. Such technologies are regarded as service innovation that serves individual footcare and allows access to quality services that meet the international standard in the context of Thailand.

The technologies used in the clinic is the application of insole manufacturing technology that are already in use in various countries, especially European countries such as Italy, France and Germany. It has been implemented and applied to suit the context of Thailand in order to be able to provide services to cover all foot diseases for more people. The clinic redesigned the government service system by using a customer centered approach and became the modern foot clinic model in Thailand and served as a learning center for government and private agencies.

1. P- walk is the pressure sensor that measures plantar pressure in static and dynamic phases. It helps diagnose the existence of postural and walking alterations. 2. Duna 3D digiplan is a scanning system developed to keep the digitalization of the foot plantar surface which will be used to design the custom insole in the special program. In combination with the CNC milling machine, a Computer Aided Manufacturing machine that is specially designed to manufacture insoles in a large quantity in less time. 3. Podiatech is the insole manufacturing technology that enables the delivery of custom insole in 1 hour.

“Innovative Foot Orthotic Clinic '' provides services that cover all conditions and respond to individual foot problems. Knowledge is transferred through academic works and seminars, for example, the National academic conference and the 11thNational Academic Seminar on Persons with Disabilities Exhibition 2019. This is the platform for stakeholders in service provision for persons with disabilities. The acceptance to share in this conference indicated the quality service for the vulnerable. Moreover, the clinic received the Public Service Awards in Service Innovation branch at Good level in year 2021 by the Office of the Public Sector Development Commission (OPDC). This award is given to the organizations that commit in improving service quality and achieve the outcome of convenience, time-saving, transparency, fair and satisfaction of client. Furthermore, it cooperates with Mahidol university in Prosthetics and Orthotics training(distance learning course) . It also provides on-the-job training program for medical personnel all over the countries.

Innovative Foot Orthotic Clinic has always been the reference center on foot health problems for the relevant agencies. Here are some examples of training courses by IFOC. 1. Foot orthoses and shoes for diabetes course in 2012, 53 participants 2. Foot orthoses manufacturing course in 2014, 40 participants 3. Prosthetic and Orthotic technician course since 2016 until present, 56 participants 4. Cooperating with Sirindhorn School of Prosthetics and Orthotics, Faculty of Medicine, Siriraj Hospital, Mahidol university as training center in Prosthetics and Orthotics courses (distance learning) 5. Training Prosthetics and Orthotics students and medical personnel from regional hospitals every year such as Hat Yai hospitals, Yala Regional hospital, Pranangklao hospital etc. with more than 20 participants annually.

Innovative Foot Orthotic Clinic has implemented budget allocation, human resources, technology, and materials by annual government statements of expenditure, Department of Medical Services. Moreover, it received an enhanced facilities budget from private agencies. The clinic has created cooperation and integration among multidisciplinary teams such as physiatrists, nurses, physical therapists, and orthotists. In addition, clients and stakeholders from other institutions have played important roles in suggesting and giving feedback to develop the service system.

IFOC is operated under the Sirindhorn National Medical Rehabilitation Institute (SNMRI) which is a technical division of the Department of Medical Services, Ministry of Public Health. It is sustainable over time because of the strong level of policy support. The annual work plan and budget of relevant government agencies are sufficiently and appropriately allocated according to the policy direction and operational guidelines. Therefore, SNMRI strongly commits to cooperate with all sectors in improving academic quality and services for PWD. The development is also in accordance with the national strategy in providing fair and equal access to health service.

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Innovative Foot Orthotic Clinic has been externally evaluated by the Office of the Public Sector Development Commission (OPDC) and received the Public Service Awards, in Service Innovation branch at Good level in the year 2021. This award is given to the government agencies that have made significant improvements in service quality and have a high impact on the people in the country. Internally, the clinic has been evaluated and assessed according to Hospital Accreditation (HA) guidelines to ensure the service operation standards.

The Public Service Awards is evaluated based on 4 dimensions: 1. Problems analysis: Analyze the background and importance of the existing problems. 2. Problem solving and implementation: The concept of clinic innovation and step-by-step improvement that shows the empirical outcome. 3. Output or empirical outcome: showing the statistical outcome including the benefits received by clients. 4. Project sustainability: The key lessons are taken for further use and in accordance with the SDGs. Internally, the clinic is evaluated based on Hospital Accreditation and percentage of patient satisfaction with the service and percentage of patients accessing quality services according to professional standards.

The award and evaluations received show that the development is on the right track. The service provided 100% patient satisfaction and the award guaranteed the efficiency of the clinic. This draws attention from many stakeholders and the public to aware of the importance of foot care. The Ministry of Public Health has launched the policy to establish a network of foot clinics at hospitals across the country using Innovative Foot Orthotic Clinic as a role model.

Innovative Foot Orthotic Clinic has created a coordination network among relevant government agencies, international agencies, multidisciplinary teams and community by applying prosthetic and orthotic experiences from around the world adapted to Thailand’s context under available resources. During the initial stage, the problem identification was conducted in cooperation with the Department of Medical Services and the community. The results showed that specialists in foot health care in Thailand are extremely lacking. The existing clinics operated their services without specialization, coordination and integration. Therefore, the clinic collaborated with relevant agencies and communities to develop a one-stop service for all foot conditions to formulate an integrated foot health community development plan. Each agency has operated its activities. Foot health literacy and foot orthotic production is operated by SNMRI Prosthetic and Orthotic Unit. Enhancing community, budget allocation and strengthening personnel ability is implemented by the Department of Medical Services. Foot orthotic technology is consulted by Italian Duna Company. Orthotic laboratory specialization is advised by Otto bock Company. Under the operation of innovation foot orthotic clinic roles and responsibilities, all agencies at all levels have been successfully linked without any conflicts with shared purpose to continuously improve the patient’s foot health.

Prosthetic and Orthotic Unit of Sirindhorn National Medical Rehabilitation Institute (SNMRI)is the main operating unit. The internal stakeholders include members of the medical service committee, physiotherapy unit, and nursing department. The executive committee of the institute supports the resource allocation, training and personnel development for the sustainability of the clinic. External stakeholders include clients, especially those with disabilities, and trainees who participate in the training programs. All have played important roles in the development and the clinic monitoring and evaluation.

There are three important issues that we have learned from this initiation. First, the successful development needs to be based on knowledge, experience in patient’s care, and the continual improvement process. Second, in order to achieve the common goal of multidisciplinary team, the patient-centered care concept is crucial. Third, technologies are the cornerstone of leaning the service system. The next step of the clinic consists of: The short term plan focuses on knowledge distribution to publicize and promote health literacy in foot health care. The aim is to anticipate people to realize the essential foot health care. The long term plan is promoting the foot health clinic service in the areas with limited number of Prosthetist and Orthotist personnel. Academic and service networks are to be supported in any hospital with inadequate instruments and technologies. The foot clinic will act as the facilitator and manufacture base in allocating devices to the network hospital. In this attempt, patients in the countryside would receive services close to home and reduce travel expenses.