Coordinating Clubfoot Services: A Guide

Coordinating
Clubfoot Services
A guide to developing successful clinics,
healthcare providers, and support
systems
i
Coordinating clubfoot clinics
The goal of this manual is to provide guidelines and resources for clubfoot clinic
coordination on local, regional and national levels. This manual provides tools for
creating or developing a clubfoot program and addresses best practices for clinic
management.
Objectives
After using this manual you will be able to:
- Identify the tools and resources provided within the manual and understand
how to use each item
- Understand the importance of how each resource can be used for the unique
needs of individual programs and clinics
- Apply these tools appropriately based upon specific clinic needs
ii
TABLE OF CONTENTS
INTRODUCTION ............................................................................................... IV
Goals for this section................................................................................................................ iv
Objectives for this section ........................................................................................................ iv
How to use this manual ............................................................................................................. v
What is miraclefeet.................................................................................................................. vi
The Ponseti method ............................................................................................................... viii
PART I GETTING STARTED ................................................................................... 9
1.1 ESTABLISHING PARTNERSHIPS ................................................................................................. 9
Goals for this section................................................................................................................. 9
Objectives for this section ........................................................................................................ 9
1.1.a Identifying partners in the field ..................................................................................... 10
1.1.b Establishing partnerships .............................................................................................. 12
1.2 CLINIC SETUP .....................................................................................................................18

Goals for this section............................................................................................................... 18
Objectives for this section ...................................................................................................... 18
1.2.a Clinic staff....................................................................................................................... 19
1.2.b Staff training resource.................................................................................................... 23
1.2.c Clinic infrastructure ....................................................................................................... 29
1.2.d Supplies and inventory .................................................................................................. 31
1.3 CLINIC SYSTEMS AND PATIENT FLOW .....................................................................................32

Goals for this section .............................................................................................................. 32
Objectives for this section ...................................................................................................... 32
1.3.a Patient medical records ................................................................................................. 33
1.3.b International Clubfoot Registry (ICR) data entry ........................................................... 37
1.3.c Scheduling and follow-up .............................................................................................. 39
1.3.d Parent Education ............................................................................................................ 42
1.3.e Family needs assessments ............................................................................................. 45
1.3.f Long term follow-up ........................................................................................................ 47
1.3.g Community Outreach..................................................................................................... 48
PART II ONGONG MANAGEMENT ...................................................................... 49

2.1 ONGOING CLINIC MANAGEMENT ...........................................................................................49
Objectives for this section ....................................................................................................... 49
2.1.a Supply chain and inventory management...................................................................... 50
2.1.b Monitoring administration and treatment ...................................................................... 56
2.2 ADVOCACY AND POLICY CHANGE .........................................................................................59

Objectives for this section ....................................................................................................... 59
2.2.a Advocacy and collaboration on the local level ............................................................. 60
2.2.b Policy on an international level ..................................................................................... 64
APPENDIX ........................................................................................................ 69
iii
Introduction
miraclefeet and program partnership
Goal
The goal of this section is to provide an understanding of the miraclefeet organization and the
role that program partnership plays in its mission to increase access to proper treatment for
children born with clubfoot in developing countries.
Objectives
After reading this introduction, you will be able to:
- Identify the goals and mission of miraclefeet
- Understand the importance of the Ponseti method in the treatment of congenital clubfoot
among children in developing countries
- Identify resources within this manual as a means for supporting best program coordination
practices
iv
How to use this manual
Layout of the miraclefeet program manual
This manual is designed to serve as a guide to coordinating clubfoot programs and. It provides
guidelines, recommendations, minimum standards, and tools to ensure the smooth flow of clinical
and administrative procedures, as well as best clinical practices. This manual is divided into
sections that address the different facets of program coordination.
Each section contains:
- Goals: explaining what the section is about and what information the section will provide
- Objectives: providing an outline of the content and materials the reader will understand
by the end of the section
- Resources in this section: A detailed table of the tools and resources that are described
in each section along with reference to where the resources can be found in the appendix
Additionally, each section provides core content that includes detailed descriptions of resource
materials. Each resource item is cataloged by its corresponding chapter number and can be
found in the appendix of this manual.
v
A brief introduction to miraclefeet
miraclefeet-supported programs
Miraclefeet` is a non-profit organization, headquartered in North Carolina, USA, dedicated to

increasing access to proper treatment for all children born with clubfoot in developing countries.
miraclefeet was created in 2008 by a group of orthopedic surgeons and concerned parents of
children born with clubfoot.
The Ponseti Method

Historically, clubfoot was treated with complicated orthopedic surgery. In addition to being
expensive and difficult on children, surgery has poor long-term results. However, the Ponseti
Method is an effective, non-surgical treatment that makes it possible to treat clubfoot
inexpensively and effectively on a global scale. Studies show a 95% effective rate of correction
can be achieved if the treatment is done properly and starts before age two. The majority of
children born with clubfoot in the developing world have little access to treatment.
Progress to Date
miraclefeet’s first program was launched with a local partner in São Paulo, Brazil in October 2010.
Since then, miraclefeet has developed partnerships with clinics around the world, including
Mexico, Ecuador, Nicaragua, India, Liberia, South Africa, Namibia, Tanzania, Botswana and
Zimbabwe. By the end of 2014, miraclefeet had supported the treatment of over 6,000 children in
over 100 clinics around the world and plans to support the treatment of 12,000 children by 2016.
miraclefeet is funded by individuals, foundations and corporations, including the Ronald
McDonald Foundation, the Oak Foundation and Clark Foundation.
The miraclefeet Approach

miraclefeet believes that partnerships with health-care providers in public hospitals and clinics
are the most effective and sustainable approach to prevent the significant disability caused by
untreated clubfoot around the world.
miraclefeet helps to improve access to free or low-cost treatment for all children by partnering
with participating clinics to provide additional training, financial support for supplies, including
braces. Because bracing is such a critical component of treatment success; miraclefeet partnered
with the Stanford University Design School and Clarks Shoes to develop a low-cost, easy-to-use
brace that will be available in 2015. miraclefeet also partners with parent groups, rehabilitation
professionals, NGOs, and health agencies at the local, state and national levels.
vi
How miraclefeet supports partner hospitals or clinics:
 Training in the Ponseti method
 On-going technical support
 Clinic supplies, including casting materials, as needed
 Braces for all children in the program
 Support for clinic set up including equipment and administrative supplies, as needed
 Access to an International Clubfoot Registry (ICR) patient database
 Human resources to help with parent education, follow up, community outreach, database
management and reporting requirements
 Quality outreach materials and parent education brochures in multiple languages
 Program development support
 A true partnership to help develop a sustainable solution to untreated clubfoot
What miraclefeet expects of partner hospitals or clinics:

 Support for the Ponseti Method as the preferred treatment for all clubfoot cases
 Utilize the patient ICR database to track treatment quality and success
 Manage of grant funds judiciously and submit financial reports
 Engage in community outreach to identify new patients
 Educate parents about clubfoot and the Ponseti method to ensure full compliance
For more information about miraclefeet, please visit http://www.miraclefeet.org
vii
The Ponseti method
Use of best clinical practices in the field
Many interventions have been used over the years to correct clubfoot, but in recent
decades, the Ponseti method of has been established as the gold standard for idiopathic
congenital clubfoot treatment.1 The Ponseti method uses a series of specific stretching techniques
to manipulate the foot into a corrected position. The foot is then placed in a toe-to-groin plaster
cast to maintain this position. The foot is manipulated and re-cast every five to seven days. This
occurs for between 6 to 8 treatments, at which point the child may require a tenotomy and then
transitions to wearing a foot abduction brace for a graduated duration of time beginning with 24
hours a day and tapering off to 12 hours per day over a period of four to five years.2
The Ponseti method of clubfoot treatment has additional benefits beyond its optimal
corrective outcomes, particularly when applied to the developing world. Because it requires few
specialty resources or tools, it is an accessible method of clubfoot treatment in regions of limited
infrastructure. The method is minimally-invasive which reduces the risks of secondary surgical
infections. Surgical interventions can be particularly problematic in developing countries with
weak health delivery systems because of the increased risk of surgeries that may be performed
inaccurately or without appropriate tools, sterile conditions, or inadequately trained staff.
The Ponseti method makes clubfoot treatment, safer, more accessible and more effective
by avoiding the risks of major surgical interventions entirely. The Ponseti is also ideal for limited
resource setting because various health care providers can be trained in the Ponseti method.
While it is recommended that physicians monitor and supervise treatment, other qualified health
care providers can be trained to perform manipulation and casting. This allows for greater
numbers of care providers in the field who are able to perform the technique.3 For all of these
reasons, the Ponseti method is rapidly being accepted as the standard of care on a global scale,
including in low- and middle-income countries around the world.
1
Radler C. The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment
recommendations. Int Orthop. 2013 Sep;37(9):1747-53. doi: 10.1007/s00264-013-2031-1. Epub 2013 Aug 9.
2
Lohan I. Treatment of congenital clubfoot using the Ponseti method: Workshop manual 2nd ed. Global-Help. 2006.
3
World Health Organization. Basic surgery training to save lives and prevent disability. Website
http://www.who.int/mediacentre/news/notes/2007/np30/en/. 2007. Accessed October 1, 2014.
viii
Establishing Partnerships
engaging hospitals and clinics
Goal
The goal of this section is to provide an understanding of what goes into establishing partnerships
with hospitals or existing clubfoot clinics. Each partnership is unique and involves identifying the
needs of partnering organizations, the community being served, as well as the region in which
the services are taking place. This section provides useful tips, tools and resources for
establishing quality partnerships that allow clinics to operate smoothly.
Objectives
After reading this section, you will be able to:
- Identify and evaluate the potential for quality partnerships
9
Identifying Partners in the Field
Establishing partnerships with hospitals and care providers
Resources in this section

Document Detail Found
1.1.a.1 Treatment Partner Application to be completed by clinics, hospitals and programs Appendix 1.1.a.1
Application interested in partnering with miralcefeet
What makes a clinical partner?

miraclefeet partnerships are designed to help clubfoot care providers and organizations deliver
effective and safe clubfoot treatment for children who would not otherwise receive care. These
partnerships seek to improve the quality of treatment and increase the numbers of children who
are able to receive treatment. Partners should have an understanding of what to expect from a
miraclefeet partnership, and be willing to maintain mutually accepted standards of clinical care.
Organizations or healthcare providers who are interested in partnering with miraclefeet can
complete the Treatment Partner Application 1.1.a.1.
10
miraclefeet partners agree to:
 Support for the Ponseti Method as the preferred treatment for all clubfoot cases
 Utilize the patient ICR database to track treatment quality and success
 Manage of grant funds judiciously and submit financial reports
 Engage in community outreach to identify new patients
 Educate parents about clubfoot and the Ponseti method to ensure full compliance
Treatment Partner Application: Helps

miraclefeet supported programs determine
a potential partner’s clinical history,
strengths, weaknesses and where support is
most needed. Decisions for proceeding with
partnerships can be based upon the criteria
set forth in this document. Additionally, this
document outlines the general conditions
for miraclefeet partnerships.
1.1.a.1 Treatment Partner Application
11
Establishing Partnerships
Partnering with care providers and organizations
In preparing a partnership with a new clinic or hospital, multiple systems must be in place. This
section identifies some of the tasks that will be initiated before a clinic can become functional. It
can be helpful to create a timeline of anticipated activities for the first year. The following section
is designed to assist new partnerships through their first year of growth.

1.1.b.1 Launching a program Identifies areas to assess for needed support Appendix
checklist 1.1.b.1
1.1.b.2 Clinic agreement form Details partnership requirements for participating clinics as Appendix
well as overseeing programs 1.1.b.2
1.1.b.3 Individual clinic Agreement by participating agencies to meet miraclefeet Appendix
participation agreement standards 1.1.b.3
1.1.b.4 Training Report Template Captures the nature of training events. Includes a sign-in Appendix
sheet for attending staff members. 1.1.b.4
1.1.b.5 Safety and Quality Protocol Goes through safety requirements to be reviewed in the Appendix
support supervision 1.1.b.5
12
Setting up project/program coordination
Some programs or clinics will require a project coordinator who is based in a central location.
Before getting started, the coordinator should take the following steps before beginning program
development.
1. Establish an office space for administrative needs if necessary, depending upon the size of
the program/project
a. Ensure access to phone system, computer, and internet
b. Purchase administrative equipment and materials
c. Order business cards
2. Establish all organizational procedures and processes
a. Select material vendors and delivery process
b. Establish billing and reimbursement process for vendors
3. Plan, schedule and organize Ponseti training and clinical workshops where necessary
a. Prepare all medical and educational materials
b. Organize trainers
c. Manage logistical issues such as accommodation, venue, transport, etc.
4. Establish mutual understanding of responsibilities with participating clinics, including
issues of:
a. Administration
b. Participation criteria
c. Needs assessment
d. Available support
e. Clinical agreement document
5. Identify clinical staff that will be involved in treatment process
6. Develop action plan with administration and clinic staff for:
a. Clinical flow
b. Patient education
c. Clinical organization including medical records
7. Ensure that clinic has the following in place:
a. Partner agreement
b. Appropriate infrastructure
c. Supplies
d. Staff
e. Data entry requirements
f. Reporting requirements
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Criteria checklist for new partnerships
When the program coordinator considers new partnerships, it is important to understand how the
clinic currently functions in order to identify the best ways to provide support. The following
questions are useful for gathering information about the clinic and determine the kind of support
they will need. These questions are also found in a checklist format, 1.1.b.1, Launching a
program Checklist.
1.1.b.1 Launching a program Checklist
1. Treatment
a. What is the designated clubfoot clinic day and time?
b. What are the ages of the children who will be treated?
c. Who casts the children?
d. Who does the tenotomies?
e. What is the schedule for follow-up?
2. Training
a. Is new or additional training needed?
b. When will the training be?
c. Who will do the training?
d. Who will be participating?
e. What is the topic? What is the agenda?
f. Will there be a session for clinic action plans (i.e. clinic set-up, specific outreach
opportunities, etc.)?
g. If the training is to be organized internally, does the partner have training materials?
14
3. Record keeping and Data management
a. Is there a paper record system in place?
b. Is the clinic set-up on the International Clubfoot Registry Portal (ICR)? Online or
offline version? Have they been trained?
c. What is the specific plan of entering data and submitting monthly reports?
d. If a coordinator will be collecting data from multiple clinics, how will they do this?
4. Parent education and community outreach
a. Who is responsible for education?
b. What education material does the program have?
c. Are there specific patient/ community needs?
d. If materials are to be printed locally, where are they being printed? When will they
be available?
e. What specific activities are planned for identification of new patients?
f. If patient transport subsidies are to be granted, what is the process? Who is in
charge?
g. What opportunities exist locally for community outreach (nurses, midwives,
community health workers, volunteers, CBR, etc.)?
5. Administrative
a. Who will perform administrative tasks/ coordinate program or clinic activities?
b. Has each participating clinic signed a partner agreement?
c. What is the agreed upon schedule for regular communication with the miraclefeet
program manager or local program coordinator?
d. Has the coordinator or clinic staff been trained in and provided with templates for:
i. Quarterly reports
ii. Financial reports
iii. Annual report
iv. International Clubfoot Registry (ICR) management
v. Patient story submissions
6. Inventory/ supply chain management
a. How will the program get supplies and distribute them to participating clinics?
b. Is an inventory system in place?
7. Monitoring and Evaluation of Quality
a. Has coordinator been oriented to the miraclefeet checklist of monitoring and
evaluation of treatment and program activities?
b. Has a support and supervision visit schedule been established for participating
clinics?
c. What is the plan for internal program review to monitor progress toward objectives?
8. Policy and Advocacy
a. What governing bodies (local, regional, and national) should be engaged to address
clubfoot issues?
b. What is the national government’s existing policy on clubfoot and disability
treatment/rehabilitation?
c. What is the plan for facilitating policy change?
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Description of additional resources
The following forms should be signed at the beginning of a partnership to establish guidelines
and agreements for collaboration.
Clinic Agreement Form: Signed by hospital

administrators and clinic representatives partnering
with a clubfoot program. It details partnership
requirements of both the participating clubfoot clinic
as well as the overseeing clubfoot program.
1.1.b.2 Clinic Agreement

Form
Individual Participation Agreement: Signed by health

care providers participating in a clubfoot program. It is
a statement of compliance to meet the clinical,
administrative and supervisory requirements of the
partnership.
1.1.b.3 Individual Participation

Agreement
16
Training Report Template: Captures any training
activities/ workshops provided to clinical staff. It
should be completed for any miraclefeet supported
training activity. The form consists of three pages.
1. Page one calls for details of the
training.
2. Page two is a sign-in sheet for trainees.
Each person attending the training should sign his
or her name on this sheet and provide the
additional requested demographic information.
3. Page three provides guidelines for
submitting the training agenda and photo
documentation to the Program Manager.
4. The first two pages of this document,
along with the training agenda, photos, and receipts
for accrued expenses should be given to the
Program Manager when submitting the associated
budget.
1.1.b.4 Training Report Template
Safety and Quality Protocol: A set of clinical and

safety standards that must be followed by
miraclefeet partners. This form accompanies the
Individual Participation Agreement.
1.1.b.5 Safety and Quality Protocol
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Clinic Setup
Staff, infrastructure and supplies
Goal
This section provides guidelines for the supplies, tools, equipment, staff and staff-training
materials necessary to set up a successful clubfoot clinic.
Objective
- Identify the roles of necessary staff members in a clubfoot clinic
- Organize training and locate clinic education materials
- Set up a clubfoot care clinic to be safe and efficient
- Identify necessary clubfoot treatment stations
- Identify essential equipment and supplies for a clubfoot care clinic
18
Clinical Staff
Tasks performed by care providers in the clinical setting
Staffing at every clubfoot clinic is different. Depending on size and patient volume, a clinic may
have as few as two staff members responsible for performing multiple duties. A larger facility
may have many more staff members. This section addresses the staffing roles needed for a
functional clubfoot clinic, regardless of size.

1.2.a.1 Clubfoot Clinic Visit This flowchart details the events of clubfoot clinic visits by Appendix
Flowchart patient visit schedule 1.2.a.1
Staff
Staff members should be prepared to perform the following tasks:
 Conduct initial patient assessment:

o The initial assessment is typically performed by an orthopedic surgeon, doctor,
physiotherapist or health care provider trained in the Ponseti method. The initial
assessment involves documentation of treatment and collection of a complete medical
history and demographic information.
 Manipulation and casting:
o This task requires a minimum of two people. In a busy clinic, however, it may be helpful
to have multiple casting stations operating at one time.
 Complete medical records:
o Medical records for scheduled patients should be set aside in preparation for the clinic
day. They should be completely filled out at each visit. This includes completing a
Pirani score and treatment notes. It may also include taking photographs and
transcribing information into the International Clubfoot Registry (ICR). Medical records
must always be stored securely.
19
 Fit child for brace:
o This task requires that a clubfoot care provider measure the child for appropriate brace
size and order the brace, and ensure accurate fit when sending the child home with the
brace. The family should always be educated when a brace is issued.
 Perform tenotomies:
o Tenotomies must be performed by a clinician who is legally permitted and properly
trained to do this procedure.
o This task involves identifying when and if a tenotomy needs to be performed, cleaning
and preparing the procedure site with antiseptic, applying local anesthetic and
preforming the tenotomy procedure.
 Prepare field for tenotomy procedure:
o This task involves preparing the field with appropriate tenotomy blades, local
anesthetic, drapes and antiseptic, as well as holding the foot in position during
procedure.
 Ensure smooth clinical function and flow:
o This task involves ensuring that staffing needs are met for anticipated patient load on
clinic days, that inventory is maintained and supplies are available, that documentation
is maintained, accurate and orderly and that all necessary paperwork and
documentation is completed and submitted appropriately.
 Follow-up with patients:
o This task involves tracking patient schedules and scheduling their return visits,
communicating with families to remind them of their appointments and following up
with families who miss appointments.
 Educate parents:
o This task involves working as a family liaison, counselor and educator. A parent-
educator works with families to ensure understanding of the Ponseti method. They help
parents develop a full understanding of their responsibilities for at-home cast and
brace compliance. The educator must also have a relationship with families such that
families feel comfortable sharing their concerns, frustrations and other challenges. This
allows educators to help families overcome stressors that may lead to loss to follow-up.
In this capacity, the parent educator also works as a family advocates and counselor.
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Clinic Flowchart
The following section contains a clinic flowchart designed to help clinics organize their time, plan
for patient visits and schedule staffing. This flowchart was designed to:
 Ensure a smooth and efficient patient flow from start to finish, depending on
phase of treatment
 Help in determining staffing and clinic flow
 Be modified to reflect individual clinic needs and staffing
 Be printed and hung on the wall of the clinic
The clinic flowchart should be modified by each clinic. The staff members responsible for each
identified task should be entered in the blank space provided on the flowchart. Templates can be
found in appendix section 1.2.a.1.
21
22
Staff Training Resources
Clinical resources for clubfoot care providers
Resources in this section are the collaborative work of multiple organizations, orthopedic
surgeons, physiotherapists, and clubfoot care providers from around the world. All are open
source and can be found on-line or in the appendix of this manual.

Global Clubfoot Initiative training Online training resources Globalclubfoot.org
resources
Global HELP Online training resources Global-HELP.org
Ponseti International Association Training programs and online resources Ponseti.info
(PIA)
miraclefeet Online training resources miraclefeet.org
23
Global Clubfoot Initiative
Global Club Foot Initiative (GCI) consists of a consortium of individuals and organizations with
expertise in clubfoot management using the Ponseti method. One of the main activities of GCI is
to make training resources available for teaching the Ponseti method and providing information
on how to set up country clubfoot programs. Under the resources link on the GCI website,
multiple Ponseti training tools can be accessed for educational purposes. This is free and open-
source, although GCI does request that you provide your email address and affiliated clubfoot
organization.
Global Clubfoot Initiative website:

globalclubfoot.org
List of resources available through
“RESOURCES” link
24
Global HELP
Global HELP website: global-help.org
The Global-HELP Organization, (Health Education using Low-cost Publications), provides free
health-care information and is committed to making medical knowledge accessible worldwide.
Visit their website for different resources and tools, including posters and parent education
materials.
25
Treatment of Congenital Clubfoot Using
Clubfoot: Ponseti Management the Ponseti Method: Workshop Manual
Lynn Staheli, MD Iris Lohan
Among their many resources, Global-HELP offers an excellent training tool for clinicians. The
Clubfoot: Ponseti Manual by Lynn Staheli, MD provides a technical overview of Ponseti treatment
and is free to download or can be ordered in hard copy in 30 different languages. It can be
ordered or downloaded directly from the Global HELP website at: http://global-
help.org/products/clubfoot_ponseti_management/.
Another excellent Global HELP publication is Iris Lohan’s Treatment of Congenital Clubfoot Using
the Ponseti Method: Workshop Manual [2nd Edition]. Written by a physiotherapist, this manual gives
excellent detail of the Ponseti method of clubfoot treatment in a practical format, using clear
language. It is also free to download or order in hard copy in 5 different languages and can be
ordered directly from the Global HELP website at http://global-
help.org/products/treatment_of_congenital_clubfoot_using_the_ponseti_method_workshop_man
ual/.
26
Ponseti International Association
Ponseti International Association website: ponseti.info
Ponseti International Association (PIA) offers workshops

and training around the world. Training schedules can
be found on their website under “Ponseti Method
Training Programs”.
Ponseti International Association also offers Ignacio

Ponseti’s textbook, Congenital Clubfoot: Fundamentals of
Treatment [2nd Edition]. This textbook provides an
understanding of the anatomy, structures and
pathogenesis of clubfoot. It also describes the
manipulative treatment and surgical interventions of the
Ponseti method. The text is free to download from the
PIA website in three different languages.
Congenital Clubfoot:
Fundamentals of Treatment
Ignacio Ponseti, MD
27
miraclefeet
miraclefeet website: miraclefeet.org
28
Clinic Infrastructure
Setting up a clubfoot clinic

Before a clinic begins treating patients it must have some basic supplies and be set up to ensure
efficient function. This section outlines the space, tools, and resources necessary to set up a
clubfoot clinic. All clinics are different, have different resources and see different volumes of
patients. The following section will give an outline for the essentials of any clinic regardless of
size, staff or patient volume. These recommendations can be scaled up or down based upon
individual clinic need.
Stations/spaces in a clubfoot care clinic

1) A comfortable place for patients and families to wait: This should be the first area the
parents walk into. The waiting room is important for families to be able to talk to each other
and the parent educator. This space should have educational posters on the walls and
materials available to parents.
2) A space to remove casts: This space should have at least one washing tub or basin and
access to lukewarm water. A kettle may be needed to warm water and vinegar can be
made available and added to water to soften casts.
3) Assessment station: A space in the clinic should be reserved to assess children. In a busy
clinic, there may be two or three assessment stations at the same time. This space consists
of a treatment table and two chairs. At this station the clubfoot care provider will:
a. Assess the condition of the foot, leg and skin
b. Measure Pirani score and record it immediately
c. Provide parent education
4) Casting station: A space in the clinic (sometimes the same space as the assessment station
given the size and resources of the clinic) where two skilled clubfoot care providers apply
plaster casts. The providers will serve two positions in the casting station:
29
a. Manipulator: leads the treatment by manipulating and holding the foot in the
desired position
b. Assistant: applies the padding and plaster
The parent must be present during treatment, particularly at casting. The child may sit
in the parent’s lap for comfort, allowing the parent to breastfeed or soothe the child
during the procedure.
5) Tenotomy Station: The tenotomy station must be staffed by at least two people as well: the
person performing the tenotomy and a trained assistant.
a. Person performing tenotomy must be legally authorized to perform the
procedure and is responsible for:
i. Cleaning and prepping the procedure site with antiseptic
ii. Applying local anesthesia
iii. Performing tenotomy procedure when indicated
b. Trained assistant is responsible for:
i. Preparing the field with appropriate tenotomy blades, local anesthetic,
drapes and antiseptic
ii. Holding the foot in position during procedure
6) Space for Administration: Each clinic must have a space to perform documentation and a
safe place to store patient records, documents, computers, and office supplies.
30
Supplies and Inventory
Having the tools to get the job done
A Ponseti clubfoot clinic must have certain inventory and supplies. Below are lists of the minimal
equipment and supplies to maintain a clinic. It is critical that supplies be closely inventoried and
monitored so that clinics do not run out of the supplies they need and block treatment. Inventory
management will be covered in section 2.1 of this manual.
Equipment and Infrastructure Supplies

Casting supplies
- water supply for cast application and - POP (Plaster of Paris)

removal
- Cotton Padding
- buckets for soaking and removing casts
Tenotomy Supplies
- chairs for cast application (minimum of
3) - Syringes
- table for performing tenotomy - Antiseptic
- camera for photo documentation - Local anesthetic
- computer for on or off-line data input - Latex gloves

(when feasible)
Bracing Supplies
- filing cabinet or shelves
- Braces
- desk
Educational Materials
- locking cabinets for supplies
- Posters
- Brochures
o Casting Phase
o Bracing Phase
31
Clinic Systems and Patient Flow
Clinical documentation and continuity of care
Goal
The goal of this section is to address the importance of keeping medical records and establishing
patient follow-up procedures. Medical records can be kept on paper, in the International
Clubfoot Registry (ICR), or both to ensure quality and continuity of care. This section will also
provide general information on incorporating patient education, follow-up and a family needs
assessment into clinic flow as a way of keeping patients in care for the duration of treatment. It
will also address community outreach and identify techniques for incorporating community
outreach within program implementation.
Objectives
- Understand and use patient medical record documentation
- Catalogue and securely store patient medical record information
- Enter patient information into the International Clubfoot Registry (ICR)
- Use the International Clubfoot Registry (ICR) to track patient follow-up
- Understand the importance of parent education
- Understand the role that parent education plays in Ponseti treatment
- Identify major teaching time points in the course of clubfoot treatment
- Create a clinic policy for short and long-term patient follow-up
- Identify the importance of community outreach
- Locate and utilize strategies for increasing community outreach
32
Patient Medical Records
Documenting patient treatment
To maintain consistent standards of quality care, clinics must document patient information,
history and treatment progress. While every clinic has its own organizational systems, all clinics
must provide medical documentation of the patient’s care that can be universally understood by
any trained clubfoot care provider.
When determining what form of documentation works best for an individual clinic,
questions to consider include:
 What data will be reported to overseeing programs?

 Will the clinic have internet access?
 Will patient data be entered into the International Clubfoot Registry (ICR)?
Clinics that partner with miraclefeet will collect patient information in the International Clubfoot
Registry (ICR). This database can be used as the primary source of medical records for the clinic.
For clinics without computers or internet access, paper medical records will need to be kept and
later entered in the ICR.

1.3.a.1 Medical patient information, family history, medical history, Pirani scoring, tenotomy Appendix
Record documentation, brace compliance 1.3.a.1
33
Medical Record
This section will go page by page through a medical record. The document is 5 pages in length
with a two page coversheet for patient consent. Each patient is issued one medical record that is
kept on file at the clinic and updated throughout the course of their treatment.
Consent for Medical/ Surgical Treatment: To

be filled out by the guardian of the patient. It
consists of two identical pages. The first page is
given to the guardian to keep. The second page
is kept in the clinic medical record chart. It is
moved to the back of the packet and becomes
the last page of the medical record document.
1.3.a.1 Consent for Medical/Surgical

Treatment
Initial Intake and Assessment, (pg. 1)

Captures the name, age and address of the
patient as well as family history, medical history,
primary examination and diagnosis information.
1.3.a.1 Patient Demographic

Medical History
34
Pirani Score (pg. 2&3)
Contain space to note the
visit number and date, full
Pirani Score, any
complications, treatment
and tenotomy procedures.
1.3.a.1 Pirani Score
Bracing Compliance (pg.4)

Used to monitor bracing
phase of treatment. This helps
clubfoot care providers
measure brace compliance.
1.3.a.1 Bracing Compliance
35
Patient Progress Notes (pg. 5) Used for
clubfoot care providers to record additional
notes related to patient treatment or
condition.
1.3.a.1 Patient Progress Notes
Helping new clinics get started with patient medical

record keeping
When establishing patient medical record keeping, the clinic coordinator should provide
clinics with the following:
 10 printed copies of the above medical record printed and ready for use
 A master copy of the medical record for photocopying should be kept in a protective
sleeve within a clinical document binder of master copies of all forms that will be used by
the clinic
 Flash drive containing an electronic version of the medical record along with other
necessary clinic forms and documents
36
International Clubfoot Registry (ICR) Entry
Documenting patient treatment in the ICR
All documentation of patients treated must be entered into the ICR. The ICR is useful for
monitoring patient progress, treatment, quality, relapse, appointment schedules and missed
visits. Pages 1 through 3 of the paper patient medical record, discussed in section 1.3.a, directly
reflects the information captured in the ICR and can be entered immediately or at a later time
depending upon staff and internet availability. If internet access is intermittent, it is good to keep
paper documentation as backup. The following resources are designed to help programs and
clinics use the ICR successfully.

1.3.b.1 ICR database Power point presentation explaining how to enter patient Appendix
management presentation treatment information into the ICR 1.3.b.1
training
1.3.b.2 Weekly patient log for Form for patient name and Pirani score Appendix
auxiliary ICR database entry 1.3.b.2
ICR Database Training Presentation:

A power point presentation developed
to explain how to enter patient
information into the ICR.
1.3.b.1 ICR Database Management

Presentation Training
37
Weekly Patient Log for
Auxiliary ICR Data Entry:
Designed for clinics that do
not have access to the ICR
database. As new and return
patients are seen in the
clinic, their information can
be recorded here and
entered into the database at
a different location. This
form is for return patients
only. Patients entered into
the ICR for the first time will
require the long form, or
page 1 of the patient
medical record (1.3.a.1).
1.3.b.2 Weekly Patient Log for Auxiliary ICR Data Entry
This form can be used in one of two ways:
1. Patient information is written on this form at the same time as the patient medical record is
being completed. OR
2. One person takes all of the charts and transfers the necessary information onto this form, after
daily clinic hours are over.
There are then several options in getting the information into the ICR database if the data is
entered centrally by a coordinator that is not on site at the clinic:
1. Clinic staff take a photo of the sheet with a camera phone. The picture is then sent to the
coordinator by email, SMS, or WhatsApp it to another phone.
2. The paper can be delivered by hand or mail to the central location (or coordination).
3. Program staff can call clinics by phone and verbally exchange the information. Program staff
would record information onto blank version of the form while clinical staff reads off the
information.
4. A clinic staff member could take the form to an internet café and enter the information into the
ICR database, if they have been properly trained and provided with a username and
password.
38
Patient Scheduling and Follow-up
Keeping Patients in Care
To ensure optimal treatment results, it is essential that patients return to the clinic for follow-up
visits and that clubfoot care providers have a system of scheduling return visits and tracking
when patients do not return. Parents should be contacted when children miss appointments or are
lost to follow-up.

1.3.c.1 Generating clinic lists Instructions for using the ICR database to track clinic Appendix
from the ICR database attendance 1.3.c.1
1.3.c.2 Patient treatment card This take home card with clinic appointment dates Appendix
1.3.c.2
39
Maintaining Patient Schedules in the Clinic
It is essential that clinics schedule follow-up appointments for their patients and have a way to
keep track of patient appointments. Keeping track of patient visit schedules allows clinics to:
 Remind patients of their visits

 Maintain better contact with patients
 Anticipate clinic supply needs
 Decrease risk of clubfoot relapse
Every clinic must identify the best method of tracking patient visits and helping parents remember
their next appointment. Some options include:
 Keep an annual paper calendar, diary or agenda:
When a patient is seen their next visit is marked in the calendar. This allows clubfoot care
providers to see when patient appointments are coming up, both in the immediate and
distant future. They can then text message or call the patient the day or week before their
appointment to remind them. If the patient misses the appointment, the clinic will know that
an appointment has been missed and can follow-up with the parents to remind them to
return to the clinic.
 Use the ICR database:

Instructions on how to use the ICR database to track clinic appointments can be found in the
Generating Clinic Lists From the ICR Database form in appendix section 1.3.c.1.
40
Additional tool for keeping track of patients
1.3.c.2 Patient Treatment Card
Patient Treatment Card: Serves as a tool for parents to keep track of their child’s appointments.
Parents keep the card with them, and bring it to each appointment. The next appointment will be
entered at each visit next to the image that depicts the treatment phase. The appointment should
also be recorded in the clinic appointment book or ICR.
The card should be printed front and back on cardstock half-sheets in 4.25cm x 5.5cm size. An
adequate number of cards should be issued to clinics so that each patient receives a card.
This card can be linked with incentives to increase treatment compliance. For all kept
appointments the parent or child may receive shoes, school tuition, or a small reward.
41
Parent Education
The foundation of quality treatment
Parent education and clubfoot treatment

The success of the Ponseti method for clubfoot treatment depends greatly upon the knowledge,
understanding and confidence of the patient’s family members or primary at-home care
providers. Parents must identify signs of broken and ill-fitting casts and braces and ensure at-
home bracing compliance. They must be well-trained in their role as caretaker to ensure optimal
clubfoot correction. As such, parent education is essential to all clinics. Comprehensive education
includes not only one-on-one training for each parent; it also requires educational tools for clinic
and home learning.
The role of parent educators in the clinic

Parent understanding of the Ponseti method is crucial to achieving good results. If parents do not
understand or follow the instructions, problems can occur, and the possibility of recurrence or
relapse is high. Providers must explain how important the parents’ role is to successful outcomes.
Parents make the Ponseti method work!
Additionally, the treatment is often as difficult for parents as it is for children. Parents often feel
guilt and sadness about what their child must go through. Some parents think that they are
responsible for their child’s clubfoot. They worry that the child will be in pain and they feel
anxiety about the outcomes of treatment.
Through quality parent education, clubfoot care providers can assure parents that they are not to
blame for the child having clubfoot. They can explain the steps of treatment carefully, making
sure that parents understand their role in the treatment process.
42
Parent educators are responsible for:
1. Ensuring that parents are informed and educated about all phases and aspects of treatment.
2. Creating an open supportive relationship with families in which they feel safe asking questions
and seeking advice.
3. Providing emotional support for parents in issues of clubfoot treatment as well as identifying
and addressing other family health, social and personal needs that may interfere with treatment.
4. Providing counseling and additional resources such as support groups and medical and crisis
referrals as needed.
5. Maintaining up-to-date demographic and contact information for families.
6. Reminding families of appointment times, and follow-up on missed appointments.
7. Teaching parents how to handle casts and braces and ensure safety and proper fit.
Teaching pointers for each phase of Ponseti treatment
Although every clinic visit is an opportunity for education, there are pivotal times in the Ponseti
treatment schedule that are particularly important.
Consultation and Casting Phase: This phase involves the most counseling and education. It is an
opportunity for the parent educator to forge a relationship with the family. This is the time to
explain that parent support is crucial to achieve a good result for clubfoot treatment. If parents do
not understand or follow the instructions, problems can occur, and the possibility of recurrence or
relapse is high.
Key points to cover:
 Explain the cause and position of clubfoot

 Explain how the Ponseti treatment works, and how long it takes
 Emphasize that their participation is important
 Reassure them that although it will be hard for them, their child will not experience pain.
 Describe the outcome to reassure them that:
o Treatment is successful for 95% of cases
o Child will be able to walk and run on strong, pain-free feet
 Provide educational materials and resources to take home
43
2. Tenotomy and Final Cast: This phase occurs only when medically recommended and marks
the end of the casting phase. Approximately 80% of children require a tenotomy.
 Explain that most children will need a tenotomy, provided under local anesthetic because
their Achilles tendon is short and tight, pulling the heel up. If left uncorrected, children will
walk on their tiptoes.
 Explain that after the tenotomy, a final cast is applied and left on for three weeks.
 During these three weeks, the tendon repairs itself in the new lengthened position.
3.Bracing and Maintenance Phase: The bracing and maintenance phases of treatment make up
the longest portion of treatment, requiring continued family support. During this phase,
noncompliance and relapse may occur so maintaining a strong and supportive relationship with
families is essential.
 Emphasize that wearing of the brace is non-negotiable- it should be part of the routine from
the start.
 Explain the brace wear schedule.
 Explain that although the foot looks straight, it can turn back in if the brace is not worn.
 Explain that the child needs a few days to adjust to the brace; some crying is normal.
 Reinforce that the brace should not be removed if the child cries.
 Put the brace on with the parent and ask them to practice with you.
 Explain how to check for the correct position of the heel inside the shoe.
 Give them educational tools to review at home.
Emphasize that parents should come to the clinic if there is any sign of problems described in
the introductory and bracing leaflets
4. Older Children, Complex Cases and Relapses: Some patients need modified care plans.
Late-referral, recurrence, resistant, complex and syndromic clubfoot often require more support
and detailed information. These patients need a highly skilled team to diagnose and specify
treatment, and in most cases, the treatment takes longer. In less than 10% of patients the
treatment fails because the foot is complex or resistant. Some of these cases can still respond well
but a highly experienced provider must supervise the treatment. Recurrent clubfoot happens
most often when the child is not wearing the brace as instructed. The foot can be treated again
and more information given about the brace. More intensive support and education may be
needed for these families.
44
Family Needs Assessment
Establishing relationships with families to keep them in care
Often, the reasons that families do not follow up or keep appointments have nothing to do with
how well-organized a clinic may be. Instead, these issues are related to family circumstances
such as illness, loss of a job, and inability to travel to the clinic due to cost of travel. To identify
families in crisis, clinic staff should assess family needs and offer supportive services to keep and
bring children back into treatment.
A family needs assessment should be an ongoing process that takes place at every visit and
with every phone or home visit interaction. This process may be the role of a social worker, the
clubfoot care provider, or the parent educator.
45
First Visit
Establish Relationship with Family: This is essential develop trust, mutual respect and
understanding. This relationship helps make family education successful and keeps families
coming back for treatment.
Understand the Family Profile: A family profile is usually a written document of all of the family
members living in a household or who have a relationship to the care of the patient. It catalogues
their relationship to the patient and includes such information as age, occupations, and any other
pertinent information such as special needs or medical issues. The family profile should identify
the primary care provider of the patient as well as secondary and back-up care providers. This
helps clubfoot care providers to know the key family members involved in child care and
treatment. It also allows care providers to get an idea of the underlying needs, challenges and
priorities of a family.
Assess Needs and Identify Family Goals: Understand what each family sees as the greatest barrier
to treatment. Identify concerns for child treatment and within the entire family. Use this
information to identify family goals, either for clubfoot treatment or something else within the
family, like education, a particular job, saving money to buy something that will impact treatment,
etc.
Develop Assistance Plan with Family: With these goals in mind work with the family to develop an
assistance plan that will help them accomplish them. Some programs may offer transportation
subsidies to offset a family’s expenses. A well thought-out and organized plan must be in place.
Each Subsequent visit
Monitor and Modify Plans: Plans and goals will change as life events take place. It is essential to
continue to maintain strong relationships with families and update their family profiles in the
treatment record. Assistance plans will change accordingly.
46
Long-term Follow-up
Keeping patients and families through the end of treatment
At-home bracing compliance and long-term medical follow-up are essential to successful
clubfoot treatment, but can be a difficult regimen for parents to maintain. Clinics should
establish strategies to motivate families to keep their child in treatment. Long term follow-up
strategies must be developed by programs and clinics, based on the population served.
Long-term follow-up strategies to consider
SMS/Text Messaging programs: In-patient care centers:
 Remind parents of upcoming  Housing/ clinics where patients

appointment travelling long distances can stay for
 Provide encouragement periods of time between clinic visits
 Help reduce missed clinic visits  Reduces travel burden on families
 Reduce administration work with  Effective in restoring health in
automatically generated reminders instance if severe under-nutrition
Long-term compliance incentives

Transportation and food subsidies:
 Families pay a deposit for their
 Reduce missed clinic visits due to
braces. The deposit is returned to
lack of funds
them if the families comply with
 Useful when families must travel long
bracing regimen and return braces in
distances to clinic
good condition
 Some clinics have a designated
 Families are compensated with an
vehicle to pick up and drop off
incentive (money, school tuition,
children for their clinic appointments
shoes) when families comply with
treatment and bracing schedule and
Mobile clinical care and follow-up:
braces are returned in good
 Decentralize follow-up services condition
 Reduce missed clinic visits
 Minimizes travel burden on families
47
Community Outreach
Engaging the community
Community outreach involves educating the surrounding community about the importance of
clubfoot treatment so that health care providers and community members are able to recognize
clubfoot and know where to refer families so that no child is left untreated. Ideally, every child
born with clubfoot has access to medical care. However, many children do not have access to any
care, and are unaware that treatment is even possible.
Communities can be educated on the following:
What problems contribute to clubfoot going untreated?

- Poverty
- Neglect
- Lack of awareness
- Lack of resources
What can be done to overcome these problems?

Use community outreach to create awareness in communities, so that people know where how
and why to get the proper clubfoot treatment.
What is community outreach?

Community outreach is the practice of increasing public awareness about clubfoot care and
facilitating the accessing of care by people in need of treatment. It is a combined effort between
community members, local organizations, relevant government officials, doctors, schools, and
social services, working together to ensure that every child in the community is treated.
What outreach methods are effective?

- Media: Radio announcements, television commercials, text message notifications
- Community leadership: Church goers, government officials, doctors
- Advertisements: Clubfoot awareness posters hung in community centers
- Support groups: Parent support groups meet to share stories and offer encouragement
48
Ongoing Clinic Management
Keeping clinics running smoothly
Goals
The goal of ongoing clinic management is to provide partners with resources to manage supply
and administrative aspects of a clinic. The following tips and resources will ensure that clinics
have the necessary supplies at the right time and that inventory can be monitored. Additionally,
this section provides resources to monitor administrative procedures and clinical skills within
clinics.
Objectives
- Identify and use the resources necessary to track, monitor, and order clinical supplies and
inventory
- Identify and use the resources necessary for monitoring clinic administrative, inventory
and performance measures
- Understand the purpose of support supervision visits
- Be able to use or designate the use of the support supervision checklist to the
appropriately qualified health care provider
49
Supply chain and inventory management
Monitoring clinical supplies
Clinics must have consistent access to the supplies necessary for clubfoot treatment. This section
describes resources that can be used for inventory control, monitoring, and ordering of essential
tools and supplies to ensure uninterrupted clubfoot treatment.

2.1.a.1 Weekly A weekly report form that inventories plaster and fiber casts Appendix
Clubfoot Clinic 2.1.a.1
Report
2.1.a.2 Monthly A monthly report form that inventories plaster and fiber casts by week Appendix
Coordination Report 2.1.a.2
2.1.a.3 Supplies Receipt for delivered supplies Appendix
request 2.1.a.3
2.1.a.4 Stock Card A manual method of monitoring inventory on either a clinical or program Appendix
level to ensure that no clinic runs out of supplies, particularly braces 2.1.a.4
50
Making sure clinics have the supplies they need
Every program and clinic has its own way of storing and inventorying supplies. When
establishing a supply chain, remember:
1. Proper planning and anticipating needs in advance ensures adequate stock
2. Clinics must always be stocked with the supplies they need to provide treatment BEFORE
the patient arrives
3. There must be a way of tracking how supplies are used so that:
a. Clinics do not run out of supplies
b. Supplies are not stolen or wasted
Every program must develop a system that works best for them and their clinics. Below are some
systems that have worked in the past with other programs.
The monthly paper system (for clinics that do not have access to the ICR database):
 Program and clinic staff estimate the supplies a clinic will need for one month based upon
the clinic ledger for the upcoming month, or the average number of children seen in past
months. The clinic is then stocked with more supplies than would be used in an average
month. This becomes the clinic’s standard inventory. The clinic will be considered fully
stocked, when it has this fixed inventory, no more and no less.
 Each week, the clinic coordinator documents how many supplies were used in the Weekly
Clubfoot Clinic Report (2.1.a.1).
 At the end of the month, the clinic coordinator uses the Weekly Clubfoot Clinic Report
(2.1.a.1) to complete the Monthly Clubfoot Clinic Report (2.1.a.2). Depending on the
implementing program, some clinics will only use the monthly form.
 The Monthly Clubfoot Clinic Report (2.1.a.2) is given to program staff at the end of the
month. This can be done by phone report, SMS, camera photo, email, or in person.
 Program staff compare the supplies used in the Monthly Clubfoot Clinic Report (2.1.a.2)
against the number of patients seen that month. Depending on the program, this
information is available from the weekly clubfoot clinic reports, if the regional program
collects those, or from photocopies of patient medical records, or by using the customized
Monthly Report and Inventory Spreadsheet (2.1.a.4).
 From this, program staff calculate the supplies needed to bring the clinic up to its full stock.
This should match the numbers provided by the Monthly Clubfoot Clinic Report (2.1.a.2).
 Program staff procure supplies and braces from in-country suppliers or from miraclefeet
and deliver them to clinics with the Supplies Request Receipt (2.1.a.3).
 This process takes place every month. The inventory can be changed as patient
populations increase or decrease over time.
The monthly electronic system:

 Program and clinical staff estimate supplies needed for one month based upon the patient
schedule in the ICR database, or an estimate of anticipated patients if it is a new clinic. The
51
clinic is then stocked with more supplies than would be used in an average month. This
becomes the clinic’s standard inventory. The clinic will be considered fully stocked, when
it has this fixed inventory, no more and no less.
 The clinic coordinator tracks supplies used on the Monthly Clubfoot Clinic Report (2.1.a.2).
This is given to the regional program at the end of the month either by phone report, SMS,
camera photo, email, or in person.
 If the ICR database is being used by clinics, program staff can generate a list of casting
visits from the hospital report in the database. If both have been used correctly, the
database and the Monthly Clubfoot Clinic Report (2.1.a.2) should match.
 From this, program staff calculate the supplies necessary to bring the clinic back to its fully
stocked status.
 Program staff requests supplies and braces from in-country suppliers or from miraclefeet
and replenish each clinic’s supplies, along with a Supplies Request Receipt (2.1.a.3).
 This process takes place every month. The amount of stock clinics keep can be changed as
patient populations increase and decrease over time.
A model for supply chain management
52
Supply chain monitoring forms and documents
Weekly Clubfoot Clinic Report:
Tracks supplies used for clubfoot
treatment. This is filled out by the
clinical coordinator. It may be kept
for clinical records only or may be
submitted to the Program staff.
2.1.a.1 Weekly Clubfoot Clinic Report
Monthly Clubfoot Clinic

Report: Tracks supplies used
for clubfoot treatment each
week, with a place to add a
monthly total. This is filled out
by the clinical coordinator
and is submitted to the
Program staff at the end of the
month in exchange for
renewed supplies.
2.1.a.2 Monthly Clubfoot Clinic Report
53
Supplies Request Receipt: Used by programs
providing clinics with supplies or by miraclefeet.
It is useful for monitoring clinical inventory. This
can be sent by WhatsApp, email, mail or
delivered in person. This should be kept by the
coordinator in the supplies binder.
2.1.a.3 Supplies Request Receipt
Stock Card: Used by programs or

individual clinics. This can be used in
addition or as an alternative to the
weekly and monthly clinic reports. Stock
cards help keep clinics from running out
of supplies by reminding clinics to
reorder supplies when stocks are low.
Stock Cards should be printed on

cardstock paper, cut in half and kept in
an inventory box. Each inventory item
should be given its own card. For
2.1.a.4 Stock Card example, if a clinic or program uses
stock cards for the inventory of braces,
each size and style of brace should have
its own stock card. As braces are distributed, the corresponding stock card should be updated
with the date, an explanation of where the inventory went, the number of braces distributed, and
the remaining number of braces in stock. Depending upon the volume of the clinic and the types
of patients seen, each clinic will decide when to order new braces. This number can be written at
the bottom of the card for quick reference. When stock supplies fall below this number, the clinic
knows to order more supplies.
54
Monthly Report and Inventory Spreadsheets
Additionally, programs may create customized monthly reporting and inventory excel
spreadsheets to monitor clinical supplies. These computer based spreadsheets can be designed
to reflect the estimated inventory of each clinic based on patients seen using the ICR database.
This allows for the monitoring of clinic inventory. Programs can restock clinic supplies before
clinics ever run out of needed inventory. It also ensures that clinics are using appropriate
amounts of supplies for the number of patients seen. Program staff completes the top section of
the spreadsheet, indicating the number of supplies sent to a specific clinic. The spreadsheet then
estimates the number of remaining supplies in the clinic. Talk to your program manager about
setting up a monthly report and inventory spreadsheet.
55
Monitoring administration and treatment
Monitoring clinics to keep them running smoothly
Every program is responsible for making sure that administrative operations run smoothly. This
involves visiting clinics to assure that treatment is up to standard, inventory matches the monthly
reports, administrative processes are flowing smoothly, and that patient follow-up and parent
education are taking place. Depending upon the needs of individual clinics program staff will
perform clinic site visits as often as every month but no less than twice a year.
In addition to monitoring the administrative qualities of individual clinics, it is also essential that
patient treatment be monitored for consistency and quality. Monitoring clinical treatment allows
for the provision of additional support and training where necessary to produce optimal treatment
outcomes.

2.1.b.1 Clinic A checklist of clinic qualities to assess clinic administrative, treatment, and Appendix
Support Supervision inventory performance 2.1.b.1
checklist
56
Clinic Support Supervision Checklist: This checklist
serves two purposes. It is designed to be used for
Designed to be completed at a site supervision visit, a
treatment supervision or both.
When using this checklist for administrative site
supervision visits:
It addresses all aspects of clinic function including
Ponseti treatment. Some programs are on schedules
such that Ponseti treatment is assessed at a different
time from other aspects of clinical administrative
procedures.
If you are only checking administrative quality, you
can skip the shaded regions of this form. If you are
doing both administrative and Ponseti treatment
quality at the same visit, you can fill out the entire
form. 2.1.b.1 Clinic Support
How to use this checklist: Supervision Checklist
1. Before performing a supervision visit, review the checklist from the previous clinic
visit.
2. Use this to fill out section 1 of the checklist.
3. Sections 2 and 3 of the checklist can be filled out during or after the site visit.
4. The checklist should then be reviewed with the program’s medical director. With the
medical director, identify the “issues to be addressed at next clinic visit” and modify the
support and supervision plan accordingly.
5. Program staff should keep all clinic checklists on file within the appropriate clinic section
and the most recent checklist filed on top.
6. Program staff should maintain a schedule of Ponseti treatment supervision visits along with
the name of the person performing each site visit.
When using this checklist for treatment supervision visits:

When using this checklist to supervise clinical treatment, the checklist should be completed
by someone with a clinical understanding of the Ponseti method. Treatment site visits should
take place at least annually, but can be performed as often as necessary depending upon the
needs of the clinic.
57
Steps for using the Ponseti Support Supervision Checklist at a treatment supervision
visit:
1. Before the site visit, the person conducting the visit should review the checklist from the
previous clinic visit.
2. Using the information from the previous checklist, he or she will fill out section 1.
3. Sections 2 and 3 of the checklist can be filled out during or after the site visit.
4. After the site visit, the checklist should be reviewed with the program’s overseeing
physician.
5. Together, the person performing the site visit and the overseeing physician will identify the
“issues to be addressed at next clinic visit” and modify the support and supervision plan
accordingly. This information should then be shared and discussed with mangers and
coordinators of the clinic.
6. Program staff should keep all clinic checklists on file within the appropriate clinic section
and the most recent checklist filed on top. Program staff should maintain a schedule of Ponseti
treatment supervision visits along with the name of the physiotherapist performing each visit.
Findings from a treatment supervision visit may call for refresher hands-on training courses for
clinical staff.
58
Advocacy and Policy Change
Becoming sustainable and getting heard
Goal
The goal of this section is to provide recommendations for incorporating advocacy on the local
level into every day clinical practice and document the history of the international movement to
protect the rights of children with disabilities.
Objectives
- Understand the community framework for policy change
- Create program-specific goals and strategies and develop a plan of action to change local
and national policies
- Understand the recent history of international advocacy and actions towards the rights of
persons with disabilities
- Establish a relationship between international policy and local action in the field
59
Advocacy on the local level
Raising awareness to create change
In order for local governments, medical institutions and national stakeholders to identify clubfoot
correction as a medical issue deserving resources and attention, care providers must make the
work they do known. This section provides resources for clubfoot care providers to work within
their own communities to change health policy and help provide sustainability and support for the
cause of clubfoot treatment in their country.
To increase public awareness of clubfoot and the Ponseti method, work must be done to bring
this issue to the attention of policy makers. When families, clinics and programs lobby for
regional and national support, they are able to garner strength and aggregate funds, legal
protections and resources. This means that more children receive treatment and more disabilities
are prevented.
60
Becoming an advocate for patients and families
Challenges
Many challenges to when working to influence policy change with children with disabilities,
including those with clubfoot. Often advocates are working against multiple barriers:
o Negative perceptions of people with disabilities

o Lack of quality guidelines and standards
o Absence of self-advocacy by patients and families
o Lack of funds designated specifically for clubfoot treatment
Policy Changes and Scope of Practice for Clubfoot Care Providers

In accordance with the rights of persons with disabilities on the international level, clubfoot care
providers can act as advocates to forge relationships with community partners, increase
awareness of local need and develop an action plan for their community, region, and country.
Each clinic or program should work to create an action plan for their region. In creating an action
plan, refer to the World Health Organization global disability Action plan 2014-2021: Better
health for all people with Disability on page 67 as a guide.
How can clubfoot care providers, in collaboration with parents, advocate to accomplish the
following in your community and beyond?
1. Remove barriers and improve access to health services and programs;

2. Strengthen and extend rehabilitation, habilitation, assistive technology,
assistance and support services, and community-based rehabilitation;
3. Strengthen collection of relevant and internationally comparable data on
disability and support research on disability and related services.
You can find examples of sample national policy strategies and plans of action at the World Health
Organization website http://www.who.int/disabilities/policies/documents/en/
It is important to break down your goals into targeted strategies so that they are easier to
achieve.
61
Strategies for including policy change in program
development plans
o Include advocacy goals and strategies in annual program plans and proposal
o Devise a plan to identify local healthcare, governmental and non-governmental partners
As a clubfoot care provider, you deliver a much-needed service to your community.
 In engaging community members, think first about groups of people for whom your
work has a direct impact: referring clinics, hospitals, doctors, nurses, orthopedists,
midwives and health outreach workers.
 Identify educational institutions and universities that can train students
 Consider groups and agencies in your community who work closely with children,
or with disabilities.
 Think about the businesses that may be associated with the work that you do. This
could include orthotics production, distribution suppliers, and businesses located
near the clubfoot clinic.
 Whenever you interact with community members, tell them what you are doing and
the ways in which you are trying to garner support.
 Consider engaging community groups such as schools, advocacy groups,
volunteer, and religions organizations.
 Consider private individuals citizens, such as parents, family members, neighbors,
friends and colleagues
 Engaging in this type of community-level networking is fundamental to advocacy
and policy change as it creates allies and cultivates grass root support.
o Work to engage the Ministry of Health or overseeing national medical agency

 Invite representatives of the Ministry of Health to regular advocacy meetings
 Request that your Ministry of Health issue a policy statement for early treatment of
children with clubfoot
 Ask the Ministry of Health to provide an invitation or letter of support for your
program or partner clinics
 Secure ongoing material support or cost sharing from the Ministry of Health
o Devise a plan to identify local healthcare, governmental and non-governmental partners
62
o Establish a professional association or National Network
 The role of a professional association is to bring together experts in the field of
clubfoot care in order to develop and assure best practice policies in implementing
the Ponseti Method as well as to garner support and awareness of the Ponseti
Method in treating clubfoot.
 It is important to collaborate with experts in your local or national community in
order to forge this solidarity, create a unified political voice, and collaborate in the
monitoring of educational programs and set professional standards.
 Professional associations are necessary on the community, national, and
international levels.
o Educate your policymakers

 Locate the people in your community who are responsible for making policy around
children, healthcare and disability rights.
 Provide them with information –specifically written materials with an overview-
about the work you are doing and what needs to change.
 Make sure your message is brief, simple and effective. Keep it within a local context.
Remember the power of a story. Telling a personal story can sometimes be the most
powerful way to engage people. Use of before and after photographs are also a
concise and cost effective method of presenting a clear message.
Dr. Morcuende encouraged members of the audience—all presidents of national, regional, or

multinational orthopaedic associations—to get involved in supporting training and practice of the
Ponseti method in their countries. He recognized the uphill battle that some might face, because the
Ponseti method, like the polio vaccine, eliminates the need for surgeries. “It can have a tremendous
impact,” he said, “but change doesn’t happen just because something works.” The care pathway
for clubfoot treatment—identification, referral, diagnosis, treatment, and follow-up—depends not
only on training providers and supplying materials and staff, but also on policy awareness.
National orthopaedic associations, he pointed out, are key in creating that policy awareness.
Adopting position statements that support the use of the Ponseti method, making the case to
healthcare administrators, health ministries, and the media, and institutionalizing training of the
Ponseti method in medical education are all ways in which national orthopaedic associations can
make a difference.
~ Chief Medical Director of the Ponseti International Association on the role of

professional associations
63
Policy on the international level
How international policy impacts work in the field
Resources in this section: International policy statements

related to clubfoot
World Health Organization International http://www.who.int/classifications/icf/icf_more/en/
Classification of Functioning, Disability and Health
World Health Organization Convention on the http://www.who.int/disabilities/media/news/unconvention/en
Rights of Persons with Disabilities
World Health Organization Global Disability Action http://www.who.int/disabilities/actionplan/en/
Plan
United Nations Standard Rules on the Equalization of http://www.un.org/disabilities/convention/signature.shtml
Opportunities of Persons with Disabilities
World Report on Disability http://www.who.int/disabilities/world_report/2011/en/
Globally, focus is shifting towards the acknowledgement of the rights of people with disabilities.
As healthcare providers and advocates watch the political landscape shift, now more than ever is
the time to create the necessary groundwork to meet this rising attention.
In addition to the congenital factors that are responsible for the development of club foot,
environmental and biological factors work to reduce or enhance the severity of childhood
disability. One of the most significant risk factors is poverty, in which children are subjected to
poor health, limited medical care, inadequate housing, poor education and increased mental
stress.
In order to impact policy on the local, national and international level, clinicians and educators
from the field are essential to instigating the policy changes and advocating for the children they
work to serve. It is important that the people working for and with children with disabilities
advocate for policy change on behalf of the children so that their voices will be heard.
64
Recent history of international rights of persons with disabilities
2001 The World Health Organization creates International Classification of Functioning,

Disability and Health (ICF)
 Creates a framework for measuring health and disability in individuals and populations.
This is an essential step in policy and advocacy as it creates a means by which
improvement can be measured.
 The world health organization’s world report on disability identifies disability as an
interaction between health conditions and contextual factors, both personal and
environmental. In the presence of positive education, clinical care, family support system
and tools and supplies, children born with club foot do not have to suffer from disability. In
the absence of these protective factors, children can be disabled for the entirety of their
lives.
 The convention on the rights of children states that children everywhere have the right to
survival, to develop to the fullest, to be protected from harmful influences, and to
participate fully in family, cultural and social life. By this definition, it is a human right for
children to have access to the education, clinical support and appropriate bracing and
casting that can prevent lifelong disability.
http://www.who.int/classifications/icf/icf_more/en/
2006: The United Nations creates Standard Rules on the Equalization of Opportunities of
Persons with Disabilities
 Identifies the human rights of people with disabilities and leads to the adoption of the
United Nations Convention on the Rights of Persons with Disabilities (CRPD) two years
later. http://www.un.org/disabilities/convention/signature.shtml
2008: The Convention on the Rights of Persons with Disabilities

 Outlines the civil, cultural, political, social and economic rights of people with disabilities.
It becomes the compass for action at national and international levels for disability rights
work. Out of this convention comes:
o The World Report on Disability: to accurately capture the prevalence and life course of
persons with disabilities in the world
o The UN Inter-Agency Support Group (IASG): to promote and implement the agreements
of the Convention
o The WHO Task Force on Disability: to ensure that the Organization itself is accessible to
people with disabilities and to mainstream the rights of people with disabilities in
technical programs.
http://www.who.int/disabilities/media/news/unconvention/en
65
2011: The World Report on Disability
 Produced jointly by WHO and the World Bank, The World Report on Disability suggests that
more than a billion people in the world today experience disability.
 People with disabilities have generally poorer health, lower education achievements,
fewer economic opportunities and higher rates of poverty than people without disabilities.
This is largely due to the lack of services available to them and the many obstacles they
face in their everyday lives.
 The report provides the best available evidence about what works to overcome barriers to
healthcare, rehabilitation, education, employment, and support services, and to create the
environments which will enable people with disabilities to flourish.
The report provided the following recommendations:
1: Enable access to all mainstream systems and services.

People with disabilities have ordinary needs, which can and should be met through
mainstream programs and services. Mainstreaming is the process by which governments
and other stakeholders address the barriers that exclude persons with disabilities from
participating equally in any service intended for the general public, such as education,
health, employment, and social services. This requires laws, policies, institutions and
environments. Mainstreaming not only fulfils the human rights of persons with disabilities,
it can also be more cost effective.
2: Invest in programs and services for people with disabilities.

Some people with disabilities may require access to specific measures, such as
rehabilitation, support services, or vocational training, which can improve functioning and
independence and foster participation in society.
3: Adopt a national disability strategy and plan of action.

All sectors and stakeholders should collaborate on a strategy to improve the well-being of
people with disabilities. This will help improve coordination between sectors and services.
Progress should be monitored closely.
4: Involve people with disabilities.

In formulating and implementing policies, laws and services, people with disabilities
should be consulted and actively involved. At an individual level, persons with disabilities
are entitled to have control over their lives and therefore need to be consulted on issues
that concern them directly.
5: Improve human resource capacity.

Human resource capacity can be improved through effective education, training and
recruitment. For example training of health professionals, architects and designers should
include relevant content on disability and be based on human rights principles.
66
6: Provide adequate funding and improve affordability.
Adequate and sustainable funding of publicly provided services is needed to remove
financial barriers to access and ensure that good quality services are provided.
7: Increase public awareness and understanding about disability.

Mutual respect and understanding contribute to an inclusive society. It is vital to improve
public understanding of disability, confront negative perceptions, and represent disability
fairly.
8: Improve the availability and quality of data on disability.

Data need to be standardized and internationally comparable to benchmark and monitor
progress on disability policies and on the implementation of the CRPD nationally and
internationally. At the national level, disability should be included in data collection.
Dedicated disability surveys can also be carried out to gain more comprehensive
information.
9: Strengthen and support research on disability.

Research is essential for increasing public understanding about disability, informing
disability policy and programs, and efficiently allocating resources. More research is
needed, not just about the lives of people with disabilities, but also about social barriers,
and how these can be overcome.
http://www.who.int/disabilities/world_report/2011/en/
2013: World Health Organization global disability Action plan 2014-2021: Better health for all
people with Disability.
The 67th World Health Assembly adopts a resolution endorsing the WHO global disability action
plan 2014–2021: Better health for all people with disability.
 Provides a major boost to WHO and governments’ efforts to enhance the quality of life of
the one billion people around the world with disabilities.
 In line with the Convention on the Rights of Persons with Disabilities
 Simplifies and strengthen the guidelines called for by the World Report on Disability
The Action Plan has three objectives:
o Remove barriers and improve access to health services and programs

o Strengthen and extend rehabilitation, habilitation, assistive technology, assistance
and support services, and community-based rehabilitation
o Strengthen collection of relevant and internationally comparable data on disability
and support research on disability and related services
67
The new resolution urges Member States to implement the proposed actions in the Action Plan as
adapted to national priorities and specific national circumstances. It invites international and
national partners to take note of the Action Plan and its objectives, and requests the Secretariat to
provide guidance, training and technical support and submit reports on the progress achieved in
implementing the Action Plan.
At no other time in history has there been greater international support and focus on changing policy
around persons with disability. Congenital clubfoot is a common birth defect that can be safely
corrected with the use of the Ponseti method. When children are provided with clubfoot care, they
are able to avoid a life-long disability. Now is the time for individuals, care providers and families to
advocate for the change these children need and deserve.
http://www.who.int/disabilities/actionplan/en/
68
Appendix1.1.a.1
Treatment Partner Application Form

About You
Applicant Name:
Title:
Hospital/Organization
Are you a non-profit organization? Yes No
Address:
State/Province:
Postal code:
Country:
Telephone:
Fax:
Email:
Web site:
About Your Clubfoot Care Program

Do you see clubfoot patients? If yes, how are they treated/ where are they referred?
Medical professional(s) overseeing the project:
Number of medical professionals currently trained in the Ponseti Method of clubfoot treatment
and number of years using the Ponseti Method:
Number of children with clubfoot who receive care at your hospital/center each year:
Average age of children currently treated for clubfoot (at beginning of treatment):
How many children have you treated in the last year with the Ponseti Method?
How many clubfoot patients have you treated in the last year with surgery?
Do any children pay for treatment? Yes No
69
Appendix1.1.a.1
Do you offer discounts based on need? Yes No
If yes, please describe:
Number of years your organization has been involved with clubfoot care:
Does your center provide interdisciplinary team care? No Yes
If yes, specify:
Does your facility have experience providing pediatric anesthesia? No Yes
If yes, specify:
Does your facility currently provide braces and replacement shoes for clubfoot patients? No Yes
If Yes, describe program.
Who pays for the braces and replacement shoes?
How much do they cost?
What brace does your facility use? Where do you get them from?
Describe what you currently do to encourage brace compliance

.
Do you have any ideas that you would like to implement to increase brace compliance?
Do you have internet access? All the time Occasionally Never
How will a miraclefeet grant or partnership with a miraclefeet supported

program help you?
What type of support is needed for your clinic?
Materials
70
Appendix1.1.a.1
Community Outreach / Family Education
Training
Clinic Set-up
Partner Requirements
By parterning with a miraclefeet program, your clinic or hospital will be asked to meet
the following requirements:
- Commit to lead with the Ponseti Method as outlined in the Ponseti Clubfoot
Management manual.
- Hold a dedicated clubfoot clinic 1-2 days a week.
- Use local anesthesia for any tenotomies that are required as part of the Ponseti Method
treatment. .
- Support bracing for up to 4 years after casting as needed, including providing braces.
- Enter patient treatment records, including photographs, into miraclefeet’s patient
database (DCA). These patient records will be reviewed by miraclefeet but will not be
shared with other institutions without your permission.
- Provide patient outreach and education of parents to ensure children born with
clubfoot are brought in for treatment and that parents understand what the treatment
involves, including the importance of brace compliance.
- Regular, in-person supervision by miraclefeet including occasional photography or video
filming of doctors and patients for marketing and fundraising purposes. miraclefeet will
seek permission from patients and their parents/guardians before any such activity.
In addition to funding treatment, miraclefeet would also like to test different brace
compliance programs. miraclefeet hopes to work closely with partner hospitals and
doctors to test different approaches to increasing brace compliance, such as parent
education and use of incentives or in-kind donations. miraclefeet may be able to
provide some additional funding to support brace compliance programs over time.
71
Appendix1.1.b.1
Checklist for Launching a Program
2. Treatment
□ What is the designated clubfoot clinic day and time?
□ What are the ages of the children who will be treated?
□ Who casts the children?
□ Who does the tenotomies?
□ What is the schedule for follow-up?
3. Parent education and community outreach
□ Who is responsible for education?
□ What education materials does the program already have? Have

the necessary materials been provided?
□ Are there specific patient/ community needs?
□ If materials are to be printed locally, where are they being

printed? When will they be available?
□ What specific activities are planned for identification of new

patients?
□ If patient transport subsidies will be granted, what is the

process? Who is in charge?
□ What opportunities exist locally for community outreach (nurses,

midwives, community health workers, volunteers, CBR, DOPs
ect.)?
4. Data management
□ Is there a paper record system in place?
□ Is the clinic set-up on the online IRC? Have they been trained?
72
Appendix1.1.b.1
□ What is the specific plan of entering data and submitting it to

miraclefeet monthly?
□ If a coordinator will be collecting data from multiple clinics, how

will they do this?
5. Training
□ When will the training be?
□ Who will do the training?
□ Who will be participating?
□ What is the topic? Do you have an agenda?
□ Will there be a session for clinic action plans (i.e. clinic set-up,
specific outreach opportunities etc,)?
□ If the training is to be organized internally, does the partner have

training materials?
6. Administrative
□ Who will be performing administrative tasks/ coordinating

program activities?
□ Who is the contact person who coordinates activities at the clinic

level?
□ Are there signed clinic partner agreements with each

participating clinic?
□ What is the agreed upon schedule for regular communication

with the miraclefeet program manager or local program
coordinator?
7. Inventory/ supply chain management
73
Appendix1.1.b.1
□ How is the program getting supplies and how are they

distributed to participating clinics?
□ Is an inventory system in place?
□ What is the plan for internal program review to monitor progress

toward objectives?
□ Has the coordinator been trained in and provided with templates

for:
□ Quarterly reports
□ Expanse reports
□ Annual reports
□ Database management
□ Patient story submissions
8. Monitoring and Evaluation of Quality
□ Has coordinator been oriented to the miraclefeet checklist of

monitoring and evaluation of treatment and program activities?
□ Has a support and supervision visit schedule been established

for participating clinics?
9. Policy and Advocacy
□ What is the national government’s existing policy on clubfoot

and disability treatment/rehabilitation?
□ Has the partner been provided with an example of proposed

guidelines for policy change to make the Ponseti method the
preferred clubfoot treatment by national government?
□ What governing body should be engaged to address clubfoot

issues?
□ What is the schedule/plan for facilitating policy chang
74
Appendix1.1.b.2
XXX Clubfoot Program: Clinic Participation Agreement

_____________________ has been selected to participate as an official clinic location as
part of the XXX Clubfoot Program. The roles and responsibility for the XXX programs and
the participating clinic are defined as follows:
XXX Clubfoot Program
The XXXP will:
1. Work with the Ministry of Health to select locations for clubfoot clinics.
2. Provide formal training to at least two qualified health workers from the selected
clinic in using the Ponseti method. Further health workers will be trained as
necessary to manage the clinic’s caseload.
3. Patients eligible for services by the XXXCP clinic are those children who report for
treatment under the age of X years at entry, who have diagnosed clubfoot. XXXCP
should be consulted in cases in which patients do not see progress after 3 casts.
4. Supply the selected clinic with XXXX, and Foot Abduction Braces as required, for the
treatment of eligible, participating clubfoot patients
5. Supply requested treatment materials and supplies on request per the Clubfoot
Supply Requisition form. Supply will only be made at a reasonable rate that
coincides with the volume of patients treated as determined by the patient
treatment records.
6. Train a counselor to work in the clinic site to work with clubfoot parents to ensure
compliance and treatment protocols, help families navigate social issues of having
clubfoot children, and do outreach in communities to increase awareness about the
availability of free clubfoot treatment. Choice of these counselors will be in
conjunction with the XXXCP coordinator, and clinic staff.
7. Provide one counselor at the clinic US$XX/month to assist in undertaking the
counseling work. This payment will cover food, airtime, and other clubfoot program
expenses.
8. will provide the clinic with educational materials for parents, including pamphlets on
casting and Foot Abduction braces and posters.
9. The initial term of this agreement is one (1) year.
Approved Participating Clinic Site
The participating clinic will:
1. Allow at least two members of its health care staff to attend initial training in the
Ponseti method, including a health professional to perform tenotomies.
2. Adhere to the Ponseti Method and will allow the XXCP to provide regular
supervision and training.
75
Appendix1.1.b.2
3. Regularly conduct a weekly clubfoot clinic, on a designated day.

4. Ensure trained staff provide treatment to patients attending the clubfoot clinic.
5. Not charge patients any fees for treatment within the XXCP.
6. The clinic will maintain a XXCP Medical Assessment and Treatment record for each
patient, and will allow these records to be copied and transferred to the XXCP
Coordinator.
7. After the initial clubfoot training is complete, each LCP clinic representative agrees
to be an advocate for the Ponseti Method and participate in training others in the
technique if required.
8. The clinic agrees to allow the XXCP to audit its patient treatment records and clinics.
9. The clinic acknowledges that misrepresentation of patients and procedures and
misuse of supplies, are grounds for cancellation of this agreement.
10. The participating clinic agrees to work with the trained XXCP counselor provided to
counsel parents of children with clubfoot at the clinic site.
APPROVED CLINIC LOCATION: ______________________________
Hospital Administrator: _________________________
Clinic Representative ___________________________
Signature: ____________________________ Date: ___________________________
XX CLUBFOOT PROGRAM
Country Coordinator: ________________________________
Signature: ____________________________ Date: ___________________________
This agreement takes effect from (dd/mm/yy): ______________________________
76
Appendix1.1.b.3
_________________Clubfoot Program:
Individual Medical Personnel Participation Agreement
My clinic/hospital location has been selected as a participating site of the _________

Clubfoot Program. As a condition of participating in this program, I agree to the
following terms:
1. I agree to treat children diagnosed with clubfoot by using the Ponseti method.
2. I will keep complete, organized and accurate records of patient care.
3. I will establish a process to ensure patient follow-up and access to bracing for the
duration of each patient’s treatment.
4. I will ensure that clubfoot practitioners have been trained in the Ponseti method as
defined by the Ponseti Clubfoot Management manual.
5. I agree to create a hospital/ clinic policy requiring that Ponseti method be used to
treat clubfoot before any other method or technique is considered.
6. I agree to designate a clinic day to the treatment of clubfoot at least one day a week.
7. I will provide an environment of safe clinical practice by committing to:
a. Safe cast removal techniques
b. Dedicated space for casting and tenotomy procedures
c. Use of sterile technique
d. Use of sedation and tenotomy procedure protocols
8. I agree to collaborate with _______________ Clubfoot Program in the review of
patient medical records for proper treatment according to the guidelines of the
ministry of health or miraclefeet.
9. I agree to promptly review all sentinel events. A sentinel event is an unexpected
event involving death or serious physical or psychological injury. Examples of
sentinel events can be found in the safety and quality protocol.
APPROVED CLINIC LOCATION: _______________________________________
Trained Medical Personnel Name [please print]: ___________________________
Signature: ____________________________ Date: ___________________________
_________________________Clubfoot Program
___________Country Coordinator Name [please

print]:________________________________
Signature: ____________________________ Date: __________________________

This agreement takes effect from (dd/mm/yy): _____________________________
77
Appendix1.1.b.4
CLUBFOOT TREATMENT TRAINING REPORT
Country:
Name of Clubfoot Program:
Provider of Training Workshop:
Dates of Training Workshop:
Training Purpose:
Other training objectives:
Training location:
Name and Position of Person Completing Report:
Organizers:
Name Position Location Employed
Host / Funding Partners:

(Please list any other organizations that assisted in funding or hosting the training workshop
Trainers / Facilitators
Name Position Location Employed
What went well: (Please outline in what ways the workshop was successful)
Challenges: (Please outline what challenges you had in conducting the workshop)
Next steps planned following training: (Outline any key activities you have planned to follow up from this
workshop. Please also outline any key recommendations you have for future training events.)
Feedback received from participants: (Summarize any feedback you received from participants)
Any other information about this training workshop:
78
Appendix1.1.b.4
Trainees in attendance: (Insert more rows as needed)
Name Email address or phone number Occupation First Organization Name Male /
Training? (public hospital, private hospital, Female
Y/N or NGO)
79
Appendix1.1.b.4
Training Workshop Agenda and event photos:

(Please insert a copy of event agenda and photographs of the event. These can be attached to this
document manually, electronically, or emailed to the program manager)
80
Appendix1.1.b.5
Safety & Quality Protocol (SQP)

Purpose: This document describes the requirements that must be met by health care organizations
performing clubfoot treatment funded by miraclefeet. The safety of the patient is always our # 1 priority.
This Safety and Quality Protocol outlines the basic elements needed to insure safe treatment and to
provide for the ongoing review and improvement of the quality of care.
Part 1: The Quality Review Process
Requirement 1.1: Keep complete, organized and accurate records of care received by patients
Part 2. Follow-up Care and Bracing
Requirement 2.1: Have a process in place to ensure patient follow-up and provide access to bracing for
the full treatment period
Part 3: Commitment to Lead with the Ponseti Method
Requirement 3.1: practitioners must be trained in the Ponseti method as defined in the Ponseti Clubfoot
Management manual (Available at
http://www.globalhelp.org/publications/books/help_ponsetiuganda.pdf)
 Have hospital/clinic policy requiring that Ponseti method be used to treat clubfoot before any
other method or technique is considered.
 Designate a dedicated clubfoot clinic at least one day a week
Part 4. Clinic Safety
Requirement 4.1: Provide an environment of safe clinical practice by committing to:
 safe casting removal techniques.
 dedicated space for casting and tenotomy procedures.
 use of sterile technique with access to working sterilizing machines, instruments and materials.
 Protocols for sedation and anesthesia protocols.
 Protocols for tenotomy procedure.
Requirement4.2: Agree to collaborate with program to review of the results of treatment by clinical staff
according to ministry of health guidelines or miraclefeet guidelines
Requirement 4.3: Promptly review all sentinel events. A sentinel event is an unexpected event involving
death or serious physical or psychological injury. Examples of sentinel events include, but are not limited
to, wounds, infections, neurological or vascular compromise.
81
Appendix1.2.a.1
82
Appendix1.2.a.1
83
Appendix 1.3.a.1
Consent for Medical/Surgical Treatment

Cover page A
[first page to be signed and given to patient/guardian]
In presenting my son/ daughter for diagnosis and treatment I,
(name of guardian) ______________________________________________ give consent for
(name of patient)________________________________________________of __________ years of age,
to the rendering of such care, including diagnostic procedures, surgical and medical treatment by members of the
clinical staff as may be necessary.
I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations
or treatment on my child’s condition.
I have read this form and certify that I understand its contents.
I hereby give my consent to (Name of Clinic/Agency)__________________________________________,
to care for my child (Name of Patient)_________________________________________________,
For the period of _________________________ to ____________________________ to provide

medical care and treatment necessary to the health of my child.
Name of guardian [printed]: ______________________________________________________

Relationship to patient: ❑Mother ❑ Father ❑ Grandparent ❑ Brother/Sister ❑ Aunt/Uncle ❑ Other
Signature of guardian: _____________________________________ Date (mm/dd/yyyy) ___/___/_____
84
Appendix 1.3.a.1
Patient Name:_____________________________ Date of Birth __________Patient number: _____________________
Consent for Medical/Surgical Treatment

Cover page B
[second page to be retained for medical record]
In presenting my son/ daughter for diagnosis and treatment I,
(name of guardian) ______________________________________________ give consent for
(name of patient)________________________________________________of __________ years of age,
to the rendering of such care, including diagnostic procedures, surgical and medical treatment by members of the clinical
staff as may be necessary.
I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations
or treatment on my child’s condition.
I have read this form and certify that I understand its contents.
I hereby give my consent to (Name of Clinic/Agency)__________________________________________,
to care for my child (Name of Patient)_________________________________________________,
For the period of _________________________ to ____________________________ to provide

medical care and treatment necessary to the health of my child.
Name of guardian [printed]: ______________________________________________________

Relationship to patient: ❑Mother ❑ Father ❑ Grandparent ❑ Brother/Sister ❑ Aunt/Uncle ❑ Other
Signature of guardian: _____________________________________ Date (mm/dd/yyyy) ___/___/_____

Appendix 1.3.a.1
Patient Name:_______________________________ Date of Birth __________Patient number: ______________________
Does the parent or guardian consent to being included in ICR database: ❑ No ❑ Yes
Does the parent/guardian consent to photographs of the patient being used for evaluation/marketing purposes: ❑ No ❑ Yes
General Information
Sex: ❑ Male ❑ Female Date of birth: (dd/mm/yyyy):
Address:
Village State/Province/District:
Parent/Guardian Information
1. Last name: First name: Middle name:
Relationship to patient: ❑Mother ❑ Father ❑ Grandparent ❑ Brother/Sister ❑ Aunt/Uncle ❑Friend ❑ Other
Phone number 1: Phone number 2:
2. Last name: First name Middle name:
Relationship to patient: ❑Mother ❑ Father ❑ Grandparent ❑ Brother/Sister ❑ Aunt/Uncle ❑Friend ❑ Other
Phone number 1: Phone number 2:
Family History
Any relatives with clubfoot? ❑ Yes ❑ No ❑ Don’t know ❑ If yes, how many?
Length of pregnancy (in weeks):
Complications during pregnancy: ❑Yes ❑No ❑Don’t know Complications during birth: ❑Yes ❑No ❑Don’t know
If yes, List complications: If yes, List complications:
Referral Information
Referral: ❑Hospital/Clinic ❑ Midwife ❑ (word of mouth) Friend/Family/Neighbour ❑ Promotional materials ❑ Other ❑ Don’t know
Specify Referral Source:
Physical Examination
Indicate other abnormalities:

❑ Head ❑ Heart/Lungs ❑ Urinary/Digestive ❑ Skin ❑ Spine
❑ Upper extremities ❑ Lower extremities ❑ Hips ❑ Neurological
Any weakness? ❑ Arms ❑ Legs ❑ Other parts of body
Comments:
Diagnosis:
Feet affected: ❑ Left ❑ Right ❑ Both
Diagnosis: ❑ Idiopathic clubfoot ❑ Syndromic clubfoot ❑ Neuropathic clubfoot ❑ Other
Deformity present at birth: ❑ Yes ❑ No ❑ Don’t know
Previous treatments: ❑ Yes ❑ No ❑ Don’t know
Type of treatment(s): ❑ Casting above knee ❑ Casting below knee ❑ Physiotherapy ❑ Don’t know ❑ Other
Diagnosed prenatally: ❑ Yes ❑ No ❑ Don’t know At week:
Diagnosis comments:
Evaluator: ______________________________Title: ______________________ Date (dd/mm/yyyy): ___/____/____
86
Appendix 1.3.a.1

Date
Visit number
L R L R L R L R L R L R L R L R
Curved lateral border
Medial Crease
LH Talus
MFC Score
Posterior Crease
Rigid Equinus
Empty Heel
HFC Score
Total Score
Abduction
Dorsiflexion
Treatment
Complications
Staff
Treatment key: C-manipulation & casting; T- tenotomy; FAB – First FAB received; REV- Review FAB
TENOTOMY
Tenotomy performed? # of Casts before tenotomy: Date of tenotomy: Date of 3-week post-tenotomy assessment:
YES  NO 
Tenotomy performed by: Degrees of abduction after tenotomy: Comments:
Name of staff assessing patient post-tenotomy: Degrees of dorsiflexion after tenotomy:
BRACE COMPLIANCE
87
Appendix 1.3.a.1
Key: 4- Applies braces every day as instructed; 3- Goes days without brace; 2- Goes weeks without brace; 1- does not use brace.
Visit Compliance Comments: Action taken/Results:
4 ❑ 3❑ 2❑
1 ❑ Don’t know ❑
4 ❑ 3❑ 2❑
4 ❑ 3❑ 2❑
4 ❑ 3❑ 2❑
4 ❑ 3❑ 2❑
4 ❑ 3❑ 2❑
4 ❑ 3❑ 2❑
4 ❑ 3❑ 2❑
4 ❑ 3❑ 2❑
4 ❑ 3❑ 2❑
88
Appendix 1.3.a.1
Patient Name:_____________________________ Date of Birth __________Patient number: _____________________
PATIENT PROGRESS NOTES

Date Comments
Appendix1.3.b.1
90
Appendix1.3.b.1
91
Appendix1.3.b.1
92
Appendix1.3.b.1
93
Appendix1.3.b.1
94
Appendix1.3.b.1
95
Appendix1.3.b.1
96
Appendix1.3.b.1
97
Appendix1.3.b.1
98
Appendix1.3.b.1
99
Appendix1.3.b.1
100
Appendix1.3.b.1
101
Appendix1.3.b.1
102
Appendix1.3.b.1
103
Appendix1.3.b.1
104
Appendix1.3.b.1
105
Appendix1.3.b.2
106
Appendix1.3.c.1
Generating Clinic Lists from the ICR Database

The ICR is a tool that makes tracking patients’ attendance quick and easy. Follow these easy steps.
The first step in using the ICR for patient attendance is registering that patient’s next visit. You do this on the visit page,
before entering the Pirani score. Simply choose the date from the calendar. Fill out the rest of the page as normal and
hit save.
Click Data Reports
107
Appendix1.3.c.1
Now, click “Visit Report”
Select “Next Visit”, “Is equal to” and choose the day you are interested in. For example, if my next clinic day is July the
23rd I may run this report on July the 20th in order to call patients and remind them. I select “Next visit” “is equal to”
“July 23, 2014.”
108
Appendix1.3.c.1
Click “Apply.”
The list of the patients that you indicated as having this date as the next visit will appear in the list below. You may print
this list. You can export this list to Excel by clicking the orange CSV button at the bottom of the page. If you do not have
the patients’ phone numbers for easy access, you can click their PATIENT ID to get them.
109
Appendix1.3.c.1
Now you have the list of patients that should be at the clinic. If someone is missing, it will be easy to see who it is and
who you need to call.
With any questions, please don’t hesitate to contact Lauren at lauren.wall@miraclefeet.org.
110
Appendix1.3.c.2
111
Appendix1.3.c.2
112
Appendix 2.1.a.1
Weekly Clubfoot Clinic Report
Clinic Location: ______________________ Clinic Date: ________________________________
Patient Name or ID Male / Age Feet Affected New/ Relapse Basic cast Tenotom First Replacemen Cotton Number of
Femal L, R, or Both Returnin Detecte L, R, or Both yY/N Brace t Brace gauze POP rolls
(if under
e 3 use g Patient d Y/N Today Issued used used
months) Y/N Today Y/N
Large Small
Patents seen: New patients: Follow-up patients: No-show patient: Diagnosed relapses: Total Casts:
Tenotomies: Braces issued: Follow-ups scheduled: Cotton: Large pop used: Small pop used:
113
Appendix 2.1.a.2
114
Appendix 2.1.a.3
Supplies Request Form
For Clinic: _________________________ Date: ___________________________
Material Quantity
Cotton
POP small
POP large
Brace size 5
Brace size 6
Brace size 7
Brace size 8
Brace size 9
Brace size 10
Brace size 11
Brace size 12
Brace size 13
Brace size 14
Given/sent by: _________________________________________
Received by:____________________
115
Appendix 2.1.a.4
116
Appendix 2.1.b.1
Clinic Support/Supervision Checklist
Name of Hospital/Clinic: _____________________________________________________________________________________

District/City/Town: _________________________________________________________________________________________
Title and name of person performing visit: ______________________________________________________________________
Date of Visit: ____________________________________ Date of last visit: __________________________________
1. Pre-visit review and plan
(To be completed before visit with information gathered from database or reports)
 Review the clinic’s performance Comments

□ Number of patients: __________
□ Average casts/child: __________
□ Tenotomy rate: __________
□ Difficult patients (more than 10 casts/child): __________
□ Follow-up rates: __________
□ Identify problems in medical treatment to be addressed in visit
 Review the clinic’s reporting performance
□ When was the last report received?___________
□ What is the quality of their form completion?______________
□ Do you need to copy treatment records on this visit?___________
□ Identify problems in reporting to be discussed with staff
 Review their material supply and determine whether you need to bring
supplies more with you during this visit. (POP, braces, educational
materials, etc.)
 Review clinic’s materials required vs. volume – is the clinic using more
plaster than necessary given the volume?
 Choose 2- 3 patients (their name and pt. number) who have been
reported to have been seen in the last month – plan to look up their files
at the clinic.
 Specific issues to be addressed during this visit (based on last visit and/or
this review:
 Are there specific ways that the clinic can be motivated, thanked and
encouraged for their work during this visit?
117
Appendix 2.1.b.1
2. Clinic visit checklist

Key staff members present at visit:
Name Role/Activity observed
 Observe activity in the waiting room Comments
□ Are patients wearing below knee casts or above knee?

□ Are returning casts in good shape or are they broken/soft? YES NO
□ Is the process of seeing patients orderly? YES NO
□ How long are patients waiting for treatment?
□ How are casts removed?
 Observe clubfoot treatment – assist in casting at least 2 patients.

Provide feedback for the caster and complete the following:
□ Who does the Pirani scoring?

□ Is it done correctly? Good Fair Poor
□ Is Pirani scoring done for follow up appointments? Yes No
□ How well are the casts being applied? Good Fair Poor
□ Is Ponseti method being strictly followed? Yes No
□ Fulcrum of manipulation was at talus; strictly NOT at calcaneocuboid
joint
□ Calcaneum was untouched throughout manipulation
□ The first metatarsal was raised, and no abduction was done (Note:
Applicable only during very first casting when cavus is apparent)
□ Focus of manipulation was on abduction, abduction, abduction (Note:
Applicable only after cavus has been resolved)
□ No passive dorsiflexion/pronation done
□ Proper molding done on talar head, malleoli, and first metatarsal
□ Cast reaches up to groin
□ Knee flexed 90 degrees
□ Cast in front of knee is thicker than back of knee
□ Five toes exposed dorsally but well supported ventrally
□ No crowding of toes
□ What is the process for scheduling/performing tenotomy?
□ How many staff in the clinic and what are their roles?
□ Ask for general feedback from staff about medical treatment
 Review medical record keeping
□ Are records secure and well organized? Yes No
□ Look up the files of the 2 or 3 patients that were preselected. Were they
easy to locate? Well organized? Are their visits completely recorded?
118
Appendix 2.1.b.1
□ Are records (patient information & Pirani scoring) properly filled out?
Yes No
 Talk to parents
□ What are their impressions of the clinic staff?
□ What are their impressions of the quality of treatment?
□ How has their interaction been with the social worker/counselor?
□ Are patients being charged? If so, how much? Y / N
□ Any concerns or complaints?
 Family and Parent education
□ Ask providers the names of the patients in the waiting room and about
their stories (to check that they know the patients).
□ Ask the provider to explain to you the Ponseti process as s/he would to a
parent.
□ Are all parents returning for appointments (casting and brace)?
□ If no, what is being done to address these problems?
 Outreach
□ Discuss the volume of patients with the clinic manager. If it is low, what
is being done to improve?
□ What activities has the clinic done to increase community awareness?
□ What has the clinic done to increase referrals and improve follow-up?
 Inventory control
□ Where are the materials kept?
_______________________________________
□ Are clubfoot materials kept apart from other materials? Yes No
□ Is the stock well organized and with ins/outs recorded? Yes No
□ Do they have enough braces, casting supplies? Yes No
□ How long will their current supplies
last?________________________________
□ Are they re-using the braces that are returned? Yes No
□ Does the clinic use any hospital materials? Yes No
 Administrative
□ Meet medical doctor or officer responsible for clinic for feedback
□ Meet the institutional administration for feedback and relationship
building
□ Are there any issues with administration systems (reporting, etc.)?
 Get a picture and story for one or two patients.
 Based on your observations, how is the clinic performing well and where is improvement needed? Discuss at end of
visit.
□ Areas in which the clinic is performing well:
119
Appendix 2.1.b.1
□ Areas needing improvement:
3. After the Clinic visit:
 Phone the clinic manager and thank him/her for their hospitality.
 Review this report with your supervising physician

 Follow up on any issues raised
Action plan:
 Address any supply or reporting issues

Action plan:
 Plan for medical or counseling refresher if necessary.
 Issues to be reviewed or addressed during next visit:
REVIEW THIS REPORT BEFORE THE NEXT VISIT!
Signed:
__________________________________________ __________________________________________
Physio conducting assessment Supervising Physician
120
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Coordinating

- Apply these tools appropriately based upon specific clinic needs

1.2 CLINIC SETUP .....................................................................................................................18

1.3 CLINIC SYSTEMS AND PATIENT FLOW .....................................................................................32

PART II ONGONG MANAGEMENT ...................................................................... 49

2.2 ADVOCACY AND POLICY CHANGE .........................................................................................59

After reading this introduction, you will be able to:

- Identify the goals and mission of miraclefeet

Miraclefeet` is a non-profit organization, headquartered in North Carolina, USA, dedicated to

The Ponseti Method

The miraclefeet Approach

What miraclefeet expects of partner hospitals or clinics:

For more information about miraclefeet, please visit http://www.miraclefeet.org

- Identify and evaluate the potential for quality partnerships

Resources in this section

What makes a clinical partner?

Treatment Partner Application: Helps

1.1.a.1 Treatment Partner Application

Resources in this section

Document Detail Found

1.1.b.1 Launching a program Checklist

Clinic Agreement Form: Signed by hospital

1.1.b.2 Clinic Agreement

Individual Participation Agreement: Signed by health

1.1.b.3 Individual Participation

Safety and Quality Protocol: A set of clinical and

1.1.b.5 Safety and Quality Protocol

- Identify the roles of necessary staff members in a clubfoot clinic

- Organize training and locate clinic education materials

- Set up a clubfoot care clinic to be safe and efficient

- Identify necessary clubfoot treatment stations

- Identify essential equipment and supplies for a clubfoot care clinic

Resources in this section

 Conduct initial patient assessment:

Resources in this section

Document Detail Found

Global Clubfoot Initiative website:

Global HELP website: global-help.org

Ponseti International Association website: ponseti.info

Ponseti International Association (PIA) offers workshops

Ponseti International Association also offers Ignacio

miraclefeet website: miraclefeet.org

Resources in this section

Stations/spaces in a clubfoot care clinic

Equipment and Infrastructure Supplies

- water supply for cast application and - POP (Plaster of Paris)

- table for performing tenotomy - Antiseptic

- camera for photo documentation - Local anesthetic

- computer for on or off-line data input - Latex gloves

- Understand and use patient medical record documentation

- Catalogue and securely store patient medical record information

- Enter patient information into the International Clubfoot Registry (ICR)

- Use the International Clubfoot Registry (ICR) to track patient follow-up

- Understand the importance of parent education

- Understand the role that parent education plays in Ponseti treatment

- Identify major teaching time points in the course of clubfoot treatment

- Create a clinic policy for short and long-term patient follow-up

- Identify the importance of community outreach

- Locate and utilize strategies for increasing community outreach

 What data will be reported to overseeing programs?

Resources in this section

Document Detail Found