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Surgery under complete asepsis
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The public healthcare delivery system in India leaves much to be desired. It should be more accessible, equitable, and affordable to the people who need it. Most and above all, it should be patient-centric rather than hospital-centric. Operation Smile, for the management of developmental abnormalities of cleft lip and palate, is one such system that operates with the efficiency of a factory which has high productivity and meets global standards of care, creating smiles and much more. This system is entirely patient-centric and consumer driven, i.e. all healthcare services are provided under one roof to meet the needs of the patients. Operation Smile’s mission, key differentiators and history, makes this organisation stand out among the top charities around the world.
Cleft lip and/or palate – A public health challenge
| Gp Capt (Dr) Sanjeev Sood |
Cleft lips and cleft palates (also called hare lip) are congenital defects that occur early in embryonic development. These are developmental abnormalities, occurring approximately in one out of 700 live births in India. A child is born with a cleft, somewhere in the world, approximately every three minutes.
Depending upon the degree of severity, cleft lip and/or palate disability may lead to interference with sucking in infants, speech articulation, swallowing and more frequent infections of upper respiratory tract, besides significant cosmetic effects. As a result, many suffer from malnutrition as well as medical and psychological problems in the long run. This is a challenging condition to treat since it needs a multidisciplinary team approach with follow up of patients for successful rehabilitation. It is estimated that there are more than one million people in India living with untreated facial deformities. Thus, this condition imposes a significant disease burden in a community and poses a major public health challenge.
Operation Smile- changing lives, healing humanity
Operation Smile was created by Dr Bill and Kathy Magee after they participated in a Philippine cleft repair mission in 1982 and recognised a need for more such missions. This is an international medical humanitarian organisation dedicated to providing lasting solutions to this problem by allowing children to be healed, regardless of their financial status– a change that brings about a more positive life along with a healthier self-image. It comprises a dedicated force of active volunteer network of more than 5,000 highly trained medical professionals who donate their time and skills on a regular basis. The organisation is headquartered in Virginia, US and is financed purely by donations and charity. Since its first mission in 1982, the organisation has comprehensively evaluated more than 3.5 million children and young adults as well as successfully treated 200,000 patients, besides training thousands of healthcare professionals worldwide. In 1996, Operation Smile was awarded the first Conrad N Hilton Humanitarian Prize in recognition of its outstanding contribution to alleviate human suffering.
International and local missions- The treatment factories
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A child with cleftlip before and after surgery
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Operation Smile’s standard International Medical Mission comprises a team of medical professionals from around the world who travel to Operation Smile partner countries for treating children during a two-week period.The partner country manages all aspects of the medical mission including physical examinations, surgery and post-operative care. The country secures its own funding, medical supplies and credentialed medical professionals or may be assisted by Operation Smile’s headquarters, a resource country or another partner country.
Operation Smile-India
Indian Medical Mission is based on the International Medical Mission model, but is conducted at the local level using Operation Smile-trained volunteers. Operation Smile India was established in 2003 as a registered Indian Trust and is run by a local Board of Directors and Medical Advisory Council. Operation Smile India’s has comprehensive cleft care centres in various parts of India which provide year-round, free reconstructive surgeries to children who suffer from facial deformities. Since the organisation’s first mission to India in 2002, Operation Smile’s volunteers have provided free medical evaluations to more than 12, 000 patients and performed life-changing surgery on more than 7, 700 children.
Operation Smile’s team have successfully completed their mission in several locations in India. The author had the opportunity to study their modus operandi, processes and workflows at some of these places. Working together with local partners they are trying to make India a ‘cleft free’ nation through a range of initiatives including the provision of restoration surgery, prenatal education and care, and community awareness programmes.
In 2004, Operation Smile India was conferred with the esteemed Diwaliben Mohanlal Mehta Award for alleviating human suffering.
| Patients getting registered | Team of diverse specialties and nationalities |
Standardised care, equipment & training- McDonaldisation of healthcare
With more than 28 years of experience in repairing facial deformities, Operation Smile have standardised their practices, equipment and anaesthesia, especially as they relate to the special needs of children, to ensure the safest surgical environment possible, the organisation adheres to 14 global standards of care that pertain to preoperative patient screening and assessment, anaesthesia equipment and supplies, surgical equipment, post-operative intensive care, patient consent, surgical priority, prevention of transmission of blood borne pathogens, pain management, a team approach to the care of patients, stringent criteria of selection, credentialing and ongoing mentoring of team members, minimum patient follow up, proper translation and standardised documentation.
State-of-the-art equipment and biomedical training is provided to all professionals to ensure that all children treated will benefit from the same quality of technology, regardless of where they receive care.
| Team members organising their stuff and handling documentation | |
Streamlined patient care processes
Medical missions usually include: two days of physical examinations, five days of surgery and four days of post-operative care, providing surgeries to approximately 125-150 patients. It costs around Rs 12,500 and can take as little as 45 minutes to repair a child’s cleft lip and change its life for the better.
On a typical mission, a team of up to 60 credentialed medical professionals (surgeons, anaesthesiologists, nurses, paediatricians, dentists and others) travel to different parts of country to treat children. The whole process of patient care and treatment delivery is highly standardised and streamlined with efficient flow of patients. This is designed into eight stations through which each patient moves sequentially.
An identification number. and file is generated containing personal and medical information of each patient (Station I). Next, patient’s photograph is taken for identification and record (Station II). Thereafter, his/her vital parameters are recorded and nursing assessment is carried out (Station III). At Station IV, patient is examined by the surgical specialist where his/her extent of disability is evaluated and eligibility for surgery is ascertained by the team. Each case is allocated a priority. Next, the case is examined by the paediatrician and anaesthetist to assess his /her fitness to undergo surgery (Station V). Then the case is seen by a dental surgeon to assess dental health and alignment (Station VI). At Station VII, a speech therapist evaluates the case for speech training and rehabilitation. Lastly, the complete data of the patient is captured in digitised and structured format in a laptop by an electronic data operator (Station VIII). This information can be quickly retrieved any time before, during or after surgery. The initial file thus created moves with the patient along these eight stations.
| Team members at their workplace | |
Safe surgeries, save lives
Operation Smile was the first cleft organisation to support the World Health Organization’s Safe Surgery Saves Lives initiative, which includes the WHO’s Surgical Safety Checklist designed to improve the safety of surgical care throughout the world. To ensure the quality of care delivered, the team moves with its own medical equipment and logistics items which are compactly stored in customised boxes. It only uses the venue (like OTs, waiting area) of local hospital. In spite of handling large numbers of patients in a short span of time the surgical site infections are barely minimal. The results of the surgery are excellent.
The non-medical support staff of the team engages with children, amusing them with positive distractions like toys and games. The whole atmosphere exuded positive energy, aesthetics and cheerful ambience, as observed by the author.
Focused factory of healthcare
| Author with team members |
The term ‘focused factory’, was introduced in a 1974 Harvard Business Review article by Wickham Skinner. Focused factory concept in healthcare is defined by R E Herzlinger as (multidisciplinary) organisations based on common objectives (e.g. the treatment of specific patient groups) that focus on patient-centered (and process-centered) care rather than professional-centred or organisation centred care. However, creating these (multidisciplinary) organisational units, might solve some of the problems associated with the traditional hospital organisation, such as; coordination problems, a work-around culture, lack of team-work, and high numbers of handovers. Operation Smile is a patient-centric healthcare system and is geared towards integrated management of developmental abnormalities of cleft lip and palate. Unlike other healthcare systems; it’s not organised towards individual doctors and discrete episodes of care but towards the comprehensive needs of patients, bringing multiple disciplines around patient care. This attribute makes Operation Smile unique from other systems of healthcare delivery.
Conclusion
Thus, driven by charity and a mission to alleviate human suffering, Operation Smile affords an excellent example of a unique model for patient care, where quality and patient centric care is delivered at patients’ door step in an efficient manner by a team of professionals, and a major public health problem is being managed with best positive outcomes that radically transforms lives and restores dignity and self esteem.