Content uploaded by Salama Raji
Author content
All content in this area was uploaded by Salama Raji on Sep 15, 2019
Content may be subject to copyright.
1
Introducing 5P’s Methodology as Healthcare
Marketing Plan: Using 5P’s Healthcare Marketing
Plan in Diabetic Foot Care Management.
Salama Jabbar Raji, Quality Management, Abu Dhabi, United Arab Emirates
P.o. Box 767252, sraji@seha.ae , telephone number +971503253526
[5P’s in healthcare marketing exploring a new approaches to find creative
solutions in order to overcome obstacles during establishing healthcare services.]
(3078 words)
Keywords Index:
1. Recommendations,
Health Planning
terms.
2. Planning
Methodology
3. Healthcare Facilities,
Manpower, and
Services
4. Health Services
Marketing
5. Evaluation
Methodology
2
Abstract
This study will focus on introducing 5P’s (Product, Place, Process, Price, and Promotion)
methodology as health care marketing study through implementing the lean process in diabetic foot
management in outpatient services in a five hundred and fifty six bed, tertiary hospital in the UAE. The
Quality specialist applied lean methodology to eliminate unnecessary staff and patient movement.
Focussing on analysing delays, defects, and variations in diabetic foot care management and
streamlining the patient pathway to improve quality and safety, reduce costs, and increase profit
margins (Arthur, 2011).
Raji, Ellahham, Aljabbari, Mananghaya, and Al Zubaidi, (2015) concluded that lean
methodology can be used to eliminate wasteful practices and reduce variation in clinical services.
Innovation in healthcare processes uses lean methodology to focus on value stream mapping of a
process (Kaplan, 2008). This in turn leads to superior utilization of hospital resources.
Introduction:
Abu Dhabi is experiencing rapid economic growth and fast becoming an attractive base for
healthcare investment (HAAD Health Statistics, 2012). The healthcare system attracts a large number
of nationals and none national workers. This leads to continuously changing demographics and
cultural social structure. The prosperity Gross Domestic Product (GDP) and life style of the population
results (The Canback Global Income Distribution Database, 2015) in an increased rate of high risk
diseases such as diabetes placing the existing health care infrastructure under pressure (HAAD Health
Statistics, 2011).
Ogrin et al. (2013) suggest that a well-coordinated multidisciplinary team is the most effective
way to provide diabetic foot management and reduce the overall burden of disability on society. A
robust support system that can sustain the diabetic population increases healthcare service demands
but improves cost efficiency and activities of daily living (Shannon, 2007).
The recent establishment of “Daman” as the national health-insurance carrier places my tertiary
hospital in a prime position to become a major regional diabetes provider. Developing a diabetic foot
centre of excellence would enable sustainment for an increased demand being placed on the current
diabetic foot care services (HAAD Health Statistics, 2013).
3
Methodology
Using lean methodology redesigns the flow of patients, materials, information and or clinicians.
This then streamlines processes and systems to improve patient outcomes. Lean innovative solutions
continuously improve processes as the industry evolves. The methodology employs a systematic
approach utilizing several tools to achieve intended outcome.
A SWOT assessment (Appendix 1) was used to analyse the Strength and Weaknesses (SW) of
the Diabetic Foot care clinic services in relation to:
1. Stakeholders, 2.Financials, 3.Customers and Community Stakeholders,
4.Service Quality & Operational Efficiency, 5. Learning Growth & Infrastructure.
A search was performed using the following databases: CINAHL, PUBMED. Search was
performed using the following key words: lean methodology, lean thinking, diabetic foot care, cost
effective, multidisciplinary team, waste reduction, value added mapping, and industrial quality
management, 60 second diabetic foot assessment with appropriate truncation.
Product
The diabetic patients who require foot care are seen across several different clinics by various staff.
Their care is not often co-ordinated well nor did treatment standardise. Our aim is to enhance patient
access and experience, reduce waiting time and improve efficient use of hospital resources and
clinical care.
There are five different clinics catering for diabetic foot care in the Outpatient Department. The
organization has a specialist, multidisciplinary care team approach that includes participation of the
wound care team. This approach although striving for positive outcomes when scrutinized recorded
measurable process waste for both patient and staff time plus clinical resources used to treat the
diabetic foot patients (Womack & Jones, 1996).
The primary goal of screening is early detection of diabetic foot problems, identifying those at
risk and planning to reduce the risk of ulcers developing. One of the most important elements of
screening is the neurological assessment for the ‘at risk’ foot ulcers (Inlows, 2004; Orted, 2009).
Woodbury et al, (2015) emphasis to perform a diabetic foot examination using monofilament within a
60 seconds assessment and collaborate with other diabetic foot team members. Nurses should
communicate with the multidisciplinary diabetic foot team after foot screening for high risk and report.
4
In diabetic foot clinic nurses may access vascular status with an ankle brachial index (ABI) and toe
pressure so as the severity of foot problems and being at risk of diabetes will be identified.
Another element of diabetic foot care excellence provided by nursing is the accurate selection of
appropriate dressing according to wound/ulcers type, e.g., wet or dry. Dressing choice is extremely
important as it is designed to keep the wound clean, maintain wound moisture levels, and support
debridement and reduction of bacteria. Accordingly, all diabetics should be referred to the diabetic
clinic in order to be evaluated, screened, diagnosed and avail comprehensive foot care annually.
Diabetic foot nurses examining patient’s feet in clinic(s) should complete the initial patient evaluation
screening list and examine the level of limb health via movement, moisture, color, temperature,
edema, pain and sensation.
Place
According to the organization’s internal data analysis, there were 29,484 diabetic outpatient visits, out
of which, 57 visits with wound complication during the studied period. For the same period of time,
17,704 patients were admitted with diabetes mellitus (Internal patients’ data analysis). Patients may
show up in late stages of their disease to the hospital. This variable means they may end up anywhere
in the hospital rather than going through the designed care pathway.
In the studied period, the hospital admitted 244 diabetic inpatients. Twenty-three of those ended
up with amputation, seven patients lower limb amputations, (3 legs and 4 toe/toes amputation).
Diabetic patients develop serious life threatening complications. The average length of stay for diabetic
amputee patients was 34.7 inpatient days (Data extracted based on principal diagnosis code, from
local internal electronic system).
Multidisciplinary teamwork is a driving force behind the success of a diabetic foot clinic, in fact
most patient pathways today (Samuel, 2014). Due mainly to an increased aging population with
comorbidities, sound teamwork has become necessary for successful patient outcomes.
Another challenge in recruiting qualified staff is the growing competition between healthcare
organizations in the UAE. Private sector service growth in the region has increased competition for
specialized staff. Specifically podiatry, a specialty service that is rare in the country.
Healthcare education in the community is still immature. Patients generally have open access to
many healthcare facilities and can choose freely whom to follow up with. Moving easily from one
5
organization to another, getting many opinions, multiple treatment approach, and this making it difficult
to follow up patients’ progress. Healthcare electronic records although advanced are not yet integrated
across the country. But they are now within our own business entities (8 hospitals). Diabetic foot care
either as a ‘service’ or social support system does not exist in this country.
Increasing outpatient clinic productivity and hospital revenue through introducing the lean
approach to DFC meant incorporating it with other in-house services to effectively manage acute and
chronic diabetic conditions. The diabetic foot clinic will be viewed as one of the important resources for
all patients as they progress from inpatient, to outpatient or extended care settings. This process will
be viewed as a centralized Diabetic Foot care management program for patient/care giver education.
Qualified, skilled and knowledgeable team members will be following this process and act as
resources and coach to improve care delivery.
A data analysis for three years internal reports (2012, 2013 and 2014) were conducted for
outpatient visits to decide the frequency of the diabetic foot care clinic. It concluded that it is better to
run the diabetic foot clinics on Sunday, Tuesday, and Thursday (in conjunction with the current surgical
clinics on Sunday and Tuesday). This eases access to refer all complicated diabetic foot to surgical
clinic where an expert opinion is available same day. Appropriate space was found that would allow for
patient privacy and resource storage.
Process
The innovative new process (Appendix 3) will focus on improving compliance through standard
patient care screening and assessment aiding early identification of high-risk patients. This process
improvement not only ensures early intervention and reduction of hospital admissions but also reduces
costs and increases patients’ satisfaction (Chadha & Kalra, 2012). The lean process begins by helping
focus on early assessment and identification of high-risk of diabetic foot patients every visit.
The existing process of diabetic foot patients’ care happens in five different clinics based on the
type of visit (Appendix 2). This process starts with registration, waiting for nurse assessment and
examination (foot care/general assessment), referral to diabetic foot clinic, possible procedure and
education. Patient then re-booked for another appointment. In case the patient needs another clinical
service (i.e. vascular consult), patient has to be re-registered again in the system. Existing policies and
procedures do not allow nurses to refer patients to different specialities; neither can nurses register
6
patients under their own services (e.g. wound care clinic), patients must be registered under a
physician name as per insurance requirements.
Diabetic foot clinic is not accessible in booking lists via registration but only through direct
appointment; requiring a special referral to be seen. These referrals are done manually as no
automated system exists. Appendix 2 shows a process map of existing journey flow for diabetic foot
patients.
The proposed new process dealt with non-value added steps in seeing diabetic foot patients. A
multi-disciplinary team was formed to study the existing process and improve it. The team consisted of
a physician, vascular surgeon, wound care nurse, quality assurance, and patient access, marketing
and finance representatives. The existing process was carefully mapped detailing all steps.
Geographical layout of five clinics was drawn and the patient journey traced. Consensus reached by all
team members including timings of each step. Follow up discussions proposed non-value added
process steps be eliminated.
Non-value added steps:
1. Duplication of patient examination
2. Duplication of registration
3. Patients’ referrals to other specialties during the visit
4. Diabetic foot re-assessment in the diabetic clinic
Appendix 3 shows new process steps and layout reflecting a leaner, efficient approach to patient care
providing effective and timely services.
Measuring outcomes of clinicians and patient adaptation to new process will be via data
extraction from electronic medical record. Extracting data from the medical record system
retrospectively includes timings of patient’s registration-assessment, examination, education/procedure
completion, and patients’ check out. This approach will be used also to standardize treatment
methods, and decrease the probability of patient complaints and incidences from delay to treat. Nurses
can also prioritize the patient’s urgency for treatment using the new process flow. The multidisciplinary
team will then triage the level of urgency by following clinical protocols or guideline (60 seconds
diabetic foot tool) (Inlows, 2004; Orted, 2009).
7
The Diabetic Foot Clinic will provide optimum healing for people with diabetic foot disease and a
holistic, coordinated wound care regime for all patients in the system.
A 5S methodology was employed to ensure proper equipment, ergonomics and environmental
best use of space (Kaplan, 2008). Adjustable table height was important to prevent staff injury.
Examination lights, separate storage cabinet for sterile instruments and consumables, hand washing
and sanitizing facilities, sizable utility rooms to keep dirty instruments were made available.
Price
All UAE national patients are covered by medical insurance and are given free treatment. Expatriates’
insurance is covered either by insurance agencies or by company sponsorship. A small minority may
be classified as self-pay. Healthcare clinicians are obliged to follow the legal regulations in terms of
providing health services.
An analysis of DFU patient’s needs from the last three years outpatients’ clinical visits has made it
possible to justify the establishment of the MDT consisting:
Two Internists
Wound Care Nurses
Orthopedic surgeon
Vascular surgeon
General surgeon
Radiologist and interventional radiologist
Microbiologist
Podiatrist
Clerk and educator
The diabetic foot clinic will help the organization by increasing registered patient visits through leaning
the existing process. This in turn increases organization revenue. Decrease of waiting time also leads
to more efficient resource utilization and organizational savings.
It is essential to keep documented history for all details of patient’s activity to manage volume
and support service line expansion. Utilization of comprehensive diabetic foot care Electronic Medical
Record (EMR) with smart workflow synchronization is key. In the facility, an electronic medical record
8
that incorporates a diabetic foot template exists. This helps clinicians’ record assessment and financial
outcome data. The data collected can be used to advance critical pathways, improve product
formularies, validate contract fee with payers and improve patient and physician satisfaction.
The medical need and expenditure for diabetic foot care have increased markedly over the past
decade. The diabetic foot centers viability is dependent on revenue, and its clinical effectiveness is
based on generated revenue and the multidisciplinary approach to diabetic foot care.
Training and education is another source of cost to the organization. It is obvious that with the
increasing prevalence of diabetes and its complications, there is undeniable a need to train nurses in
this field. The cost of training is calculated by the man-hours spent in the clinical and classroom
settings. The budget is allocated yearly as a part of the general training budget in the organization.
Diabetic foot is the most common cause of hospitalization and health system concerns in
diabetic patients. Specialized diabetic healthcare providers are assigned to the prevention and
diagnosis of diabetic foot complications. Nurses as members of the diabetes care team not only need
to play the role in clinical health care, but public education, health system management, patient case
management and monitoring the activities of daily living.
Promotion
The goals of health promotion are to achieve disease prevention, effective patient care and ensure
patients’ treatment compliance. To achieve these goals, healthcare professionals play different roles:
providing clinical care, care connectors, educators, consultants, leaders, researchers and patient
advocates. They combine science and art to provide health services, seeking to balance physical,
emotional, mental, social and cultural norms with spiritual needs.
Compliance to standard procedures, policies, guidelines through evidence-based practice, will
increase the knowledge in management of care of diabetes and diabetic foot wounds. All educational
information, trainings, conferences were offered to all staff but still there is no standard of care being
done to patients with diabetic foot wound.
Having a new process or framework requires promotion and marketing. The diabetic foot clinic
is promoted through two directions, the first by healthcare providers. This approach will be through
meetings, flyers, and circulars. All-important information will be specified in the flyer. Educational
sessions will be conducted to all involved healthcare providers on the new process and layout. Most
importantly, senior leadership engagement and support will be evidenced and regular communication
to all staff. Marketing department will be involved in the process of promoting the creation of the new
9
clinic. Other healthcare organizations will be notified and the new process and referral guidelines
explained.
The other direction will be focused on patients and community. Special patients’ education
program will be held in the clinics. This program will involve all staff involved in the patients’ journey. It
will include physicians, nurses, dieticians; wound care nurses and other professionals. Healthcare
diabetic foot care education printed materials will be developed to comply with patients and family’s
needs. Marketing department will contact local media for publicizing the new process and to educate
the community about it. The community education will focus on encouraging patients to take a direct
appointment with the diabetic foot clinic made available in the new system.
Result and discussion:
Our vision is to have a lean diabetic foot care management process in the hospital by end of
2018 that is properly equipped with all resources. The clinical information outlined in our internal
statistical reports (2012, 2013 and 2014) clearly shows the need and benefits for implementation of a
DFU lean pathway but strategies to overcome current barriers preventing the hospital from forging
ahead must be sought.
Our goal is to set up a multi-disciplinary team to implement the lean diabetic foot care process for all
patients at risk of diabetic foot ulcers with the aim to empower patients to participate in their
management. Strategies consist of a comparison of the current management of patients with diabetic
foot ulcers at the hospital to future management of these patients defined by the new lean process.
Support and approval from the senior management team is the key successful factor to
implement the lean process and resolve several barriers currently contributing to delays in
implementation.
Establishing evidence of the successful of the lean process starting with launching patient
surveys and observations of clinical practice to compare treatment before and after the establishment
of a lean DFU pathway (NICE, 2011). We plan to document the level of care and ask the patient about
quality of life criteria and monitor implementation of on-going treatment plans.
The new process results are shown below in appendix 3. Most important of these results is the
new layout having a decrease 68% in total process time and allowing for 18 additional patients per
week to register. The results of the new layout implementation (Appendix 3; Figure 1 and 2) were:
10
• Using diabetic foot care assessment as a key process.
• Having an own minor OP’s nurse.
• Educate patients to be aware of side effects and to call immediately when they have something
• Discussion with all staff to have a standard process
Also the results out of the process changes were:
• A total time reduction of 83% or 144 min (Appendix 4)
• A total waiting time reduction of 93% or 105 min (Appendix 4)
• A total process time reduction of 68% or 47 min (Appendix 4)
• Involvement of DF team
• Much reduced patient ways
Conclusion:
The 5P's (Product, Place, Process, Price, and Promotion) strategies are introduced to improve
healthcare services. The above healthcare marketing study recommend to add the 5th P (Process) as
core of healthcare marketing plan approach to improve or establish any healthcare services. A
healthcare marketing plan should be purposefully and consistently developed to be part of routine and
integrated to achieve the organization mission. These strategies (5P’s) are necessary to develop and
execute the healthcare services and growth of the profession that customers as well as the healthcare
community which can embrace these services. Considering that the support of top management is a
necessity for a transition to a market orientation (Narver and Slater, 1994) and make sure of marketing
represents a “central success factor”.
The 5P’s can guide the healthcare marketing and ensure effectively reaching the market requirements
toward providing the needed services. The right 5P’s marketing plan implementation gets into a pro-
active mode and will be part of the culture.
11
References:
Arthur, J. (2011). Lean six sigma for hospitals: Simple steps to fast, affordable, flawless healthcare. (1st
ed.). United State of America: McGraw-Hill.
Chadha, R., Singh, A., Kalra, J. (2012). Lean and queuing integration for the transformation of health
care processes: A lean health care model. Clinical Governance: An International Journal, 17(3), 191 -
199.
Dickinson, E., 1995. Using marketing principles for healthcare development. Quality in Health Care,
4(1), p.40.
Inlow, S. (2004). The 60-second Foot Exam for People with Diabetes. Wound Care Can. 2(2):1–10.
Kangarloo, H., Dionisio, J. D., Sinha, U., Johnson, D. & Taira, R. K. (1999). The case for using
industrial quality management science in health care organizations. AMIA Symp, 545–549.
Kaplan, G.S. (2008). Advanced Lean Thinking: Proven Methods to Reduce Waste and Improve Quality
in Health Care. Oakbrook Terrace: Joint Commission Resources.
King HB, Battles J, Baker DP, et al. (2008).TeamSTEPPS: Team Strategies and Tools to Enhance
Performance and Patient Safety. Agency for Healthcare Research and Quality, 5(2):5–20.
Ministry of Health, Health Authority Abu Dhabi and Dubai Health Authority. Healthcare Professionals
Qualification Requirements. (PQR 2014).
National Institute for Health and Clinical Excellence. Diabetic foot problems: inpatient management of
diabetic foot problems. Clinical guideline 119. London: NICE, 2011.
Ogrin, R., Houghton, P.E. & Thompson, G.W. (2013). Effective management of patients with diabetes
foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team. Journal of Wound Care,
12(4), 377-386.
Orsted, HL (2009). Development of the Inlow 60- second Diabetic Foot Screen: A Practice-ready
Bedside Tool to Guide Assessment and Care. Wound Care Can. 7(2):2–40.
Ohno T. Toyota Production System: Beyond Large-Scale Production. Productivity Press; New York:
1988. Original Japanese edition published in 1978 by Diamond Press.
12
Raji, S. J., Ellahham, S., Aljabbari, S., Mananghaya, T.H. & Al Zubaidi, A. (2015). Reducing Door to-
Balloon- Time for Acute ST Elevation Myocardial Infarction in Primary Percutaneous Intervention:
Transformation using Robust Performance Improvement. BMJ Quality Improvement Report, 4(1).
Samuel, N. (2014). Effective multidisciplinary working: the key to high-quality care. British Journal of
Nursing, 23(13).
Slater, S.F. and Narver, J.C., 1994. Does competitive environment moderate the market orientation-
performance relationship?. The Journal of Marketing, pp.46-55.
UAE Gross Domestic Product (GDP) results (The Canback Global Income Distribution Database,
personal communication, 2015).
United Arab Emirates. Health Statistics. (2013). Reliable Excellence in Healthcare. Abu Dhabi: HAAD.
United Arab Emirates. Health Statistics. (2012). Reliable Excellence in Healthcare. Abu Dhabi: HAAD.
United Arab Emirates. Health Statistics. (2011). Reliable Excellence in Healthcare. Abu Dhabi: HAAD.
Womack, J.P., & Jones, D. (1996). Lean Thinking: Banish Waste and Create Wealth in Your
Corporation. New York: Simon & Schuster.
Woodbury, M.G., Sibbald, R.G., Ostrow, B., Persaud, R., & Lowe, J.M. (2015). Tool for Rapid & Easy
Identification of High Risk Diabetic Foot: Validation & Clinical Pilot of the Simplified 60 Second Diabetic
Foot Screening Tool. PloS one. 10(6).
13
Appendix 1
Figure 1: DFU AWOT analysis
14
Appendix 2
Figure 1: Complicated Diabetics foot care process (the existing journey flow layout)
15
Appendix 3
Figure 1: Demonstrated the New Clinic Pathway Design (The New Lean Layout)
16
Figure 2: Innovative Diabetes Foot Care Process (The New Lean Process)
17
Appendix 4
Figure 1: Waiting time for Diabetes Foot Care Clinic before and after lean process implementation
(Results out of the changes)
