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Proposing a carpal tunnel treatment centre: The Shouldice model revisited
Hazim Sadideen, Faddy Sadideen

ABSTRACT
The Shouldice Hospital prides itself with excellent hernia repair outcomes. The Shouldice concept exhibits a unique, successful business model, and is a clear example of the concept of a highly innovative value proposition. Exploring Shouldice's fundamental principles and extrapolating them to other settings might help healthcare professionals offer improvements to patient care. Carpal tunnel syndrome (CTS) is the most common elective hand disorder, which can be debilitating for patients. Surgical intervention is extremely effective when necessary. It would be prudent to develop efficient pathways for the treatment of CTS, and other common disorders in the future. This review aims to explore the successes behind the Shouldice model, cross-fertilise surgical and management grounds by familiarising surgeons with the Shouldice model to help generate key ideas for the future, and extrapolate key information to postulate the 'carpal tunnel treatment centre' as a potential enterprise that can be designed on the basis of the Shouldice model. Optimal healthcare delivery while improving the patient journey, in a cost-effective manner, requires careful planning and execution. It is important to further explore and capitalise on this knowledge, to improve our service to patients and the multidisciplinary healthcare workforce, particularly in light of restructuring of the NHS and the reduction in training opportunities for surgical residents. Key Words: Shouldice • carpal tunnel syndrome • patient journey • surgical training
Accepted for publication 25 March 2014

Optimising healthcare delivery iu a costeffective manuer is crucial from a management perspective. This may be accomplished by providing a reputable service, shorteuiug the time from referral to treatment, and reducing the number of patient episodes. For iustauce, direct referral from a GP to a settiug where g confirmatory tests are uudertakeu, followed by I surgery itself, while allowiug patients to returu I home iu a timely manuer, can be an ideal siugle< î stage pathway for a commou surgical condition. o developed solely for surgical hernia repairs uuder local auaesthetic usiug the recognised Shouldice technique (which results iu extremely low recurrence rates), delivers afirst-classcliuical service and is an extremely successful business model. By operatiug ou healthy patieuts wdth uo medical co-morbidities aud uucomplicated heruias, it has focused ou a very narrow segment of the market, optimising its product aud service by elimiuatiug risks aud uucertaiuties associated with diversificatiou. By also providiug a 'holiday experience'

Hazim Sadideen Specialty Registrar, Department of Plastic and Reconstructive Surgery, University Hospitals Birmingham Faddy Sadideen Healthcare Consultant, London; INSEAD Alumni Email: hazim.sadideen@ doctors.org.uk

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The renowued Shouldice Hospital iu Cauada,
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post-operatively, it has been reported that Shouldice Hospital provides an extremely high quality of care, excellent patient experience and faster recovery from hernia repairs, while requiring fewer surgeons and nurses, and operating at lower costs and higher efficiency, hence charging lower prices than competitors (Nettissine, 2012). It is unsurprising that the Shouldice business model has been used as a basis for developing other specialised healthcare services globally. In 2011, the winner of The Economist innovation award in the 'business process' category was Devi Shetty of Narayana Hrudayalaya Hospital in Bangalore, for reducing healthcare costs using mass production methods. The latter hospital performs more cardiac surgery—under general anaesthesia—at lower cost, with lower mortality rates when compared to leading Western hospitals (Nettissine, 2012). However, this hospital caters for several surgical specialities, to include oncology and anaesthesia. Adopting the Shouldice concept for a certain market niche requires extensive planning, coordination and execution. What other conditions could be targeted in a similar fashion? To be precise, what other relatively common surgical conditions in healthy patients can be repaired under local anaesthesia, providing immediate therapeutic effect, of reasonable durability? Given the authors' background in plastic, reconstructive and hand surgery, and healthcare management, it is proposed that carpal tunnel decompression (CTD) for carpal tunnel syndrome (CTS) could be a potential target that would fit this model, particularly in the current NHS climate. This review will begin by briefly expanding upon the Shouldice Hospital, its history and success, without exhausting detail, because this information is widely available elsewhere (Shouldice, 2013). It will then expand upon CTS as a potential market niche that can be targeted. g It will then explore how this can be adapted into I such a model. It is hoped that this approach I will benefit readers by generating a greater I understanding of the Shouldice concept and o Adopting the Shouldice conceptfor a certain market niche requires extensive planning, coordination and execution
Shouldice Hospital
Shouldice Hospital is a modern 89-bed inpatient facility located on 23 acres in Thornhill, Ontario in Canada. From its inception in 1945 to 2003, 280 000 hernias were repaired. The eleven fulltime surgeons perform an average of 7500 hernia repairs annually (Shouldice, 2003; Shouldice, 2013). The Shouldice technique originally described and performed by Shouldice has evolved remarkably, yet many aspects remain exceptional in both the dissection and hernia repair (Shouldice, 2003). The unique laminated closure allows a tension-free repair under local anaesthesia. The entire inguinal (groin) region is dissected out and secondary hernias and abdominal wall weaknesses are searched for and repaired (ones which may present clinically in the future as hernias). The surgical repair that has evolved is durable, with low recurrence and complication rates, as demonstrated by the follow-up of tens of thousands of patients over 50 years (Shouldice, 2003). The Shouldice experience, however, consists not only of a successful surgical repair, but a unique multidisciplinary concept that involves patient cooperation in preoperative preparation and early postoperative ambulation in a relaxed, supportive environment for a couple of days prior to discharge, providing a truly holistic approach.

Carpal tunnel syndrome (CTS)
CTS is the most common elective hand disorder with a prevalence of 3-6 % (Atroshi et al, 1999; Chung, 2003). It is caused by compression of the median nerve in the wrist; its symptoms range from mild numbness and tingling in most
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3 its potential application.
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the development of efficient pathways for the treatment of this potentially debilitating disorder, such as the one-stop carpal tunnel clinic (Ball et al, 2011). Milder forms of CTS can be treated conservatively in the first instance, such as with night splints, and occasionally steroid injections for temporary relief (Piazzini et al, 2007). It must be noted that there has been a major reform in the UK healthcare system's structure following the replacement of primary care trusts (PCTs) with clinical commissioning groups (CCGs) and the prioritisation of healthcare service delivery in the UK (Primary Care Commissioning, 2013). It is still unknown whether the same clinical priorities will be commissioned or whether this will also change; this information is eagerly anticipated, although it is believed that in the immediate interim the clinical priorities will not change, rather only the commissioning process. Historically some PCTs had labelled surgery for CTS as a 'low priority', in that intermittent symptoms or mild-to-moderate disease would not be commissioned (NHS Suftolk, 2013). This may still be the case as some CCGs have adopted their 'predecessor PCT' policies, although some reshuffling may ensue (Oxford Clinical Commissioning Group, 2013). This poses a potential problem for patients whose symptoms are affecting their activities of daily living because they have mild-to-moderate CTS; as their symptoms are not 'severe enough', surgical treatment of the disease is not commissioned. This may indirectly provide demand for surgery to be undertaken in the private sector to minimise discomfort and prevent a disruption to their activities; many patients may want to avoid waiting till their symptoms are debilitating, particularly if they have not responded to conservative treatment. Furthermore, from a clinical perspective, with prolonged median nerve compression, there is a greater likelihood of permanent damage (sensory and/or motor). This should act as a clinical drive tofindways to combat this common, potentially debilitating condition that seems to have not made the commissioning process's 'priority list'. This review postulates the 'carpal tunnel
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fingers of the affected hand, to clumsiness and complete weakness. In fact, surgery for CTS is one of the most often performed procedures in the USA (Owings and Kozac, 1996). More than 40 000 patients undergo surgical decompression in the UK each year, yet this condition appears to be undertreated, as nearly 1% of the population has undiagnosed CTS that would benefit from surgery (Atroshi et al, 2003). In addition, nearly half the population with presumed CTS require in excess of 31 days off work per year (Dawson et al, 2001). Cost analysis of CTS treatment including non-tangible ones such as loss of productivity caused by sick-leave at work, led to the conclusion that confirmed CTS should be treated operatively (Korthals-de Bos et al, 2006). Thesefindingshave helped promote

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treatment centre' (CTTC) as a potential model thaf can be designed on the basis of Shouldice principles. If will target some of the successes of Shouldice, avoiding any cost-analyses or feasibility studies; it will attempt to explore the CTTC as a provider of an innovative value proposition.

Shouldice revisited
By offering a highly innovative value proposition, Shouldice has demonstrated fhat it is an exemplar enterprise, revolutionising the service experience of hernia repairs. The value proposition has become an important and widely used term in business (Anderson et al, 2006). It has been suggested that the value proposition 'should be the firm's single most important organising principle' (Webster, 2002). Because it has targeted a single, specific type of patient—i.e. patients with no major medical co-morbidities and in good health—it has avoided the need to add costly equipment in the diagnostic and therapeutic fields of medicine. Furthermore, by providing a service for a single operation (i.e. hernia repair) if does not need doctors from other specialities for possible contingencies; there is just one procedure and one system which has been optimised and standardised, analogous to how Ford standardised car assembly 100 years ago. Consequently, each doctor performs hundreds of procedures every year, maintaining extremely high quality. With no advertising campaign, the Shouldice manages to have a six-month backlog of patients. One of the main reasons behind its financial success was its powerful operating concept, or in other words, its ability to maximise fhe difference between perceived qualify and value to fhe patient, and fhe cosf of supplying its services. Examining fhis further, it is known thaf at Shouldice: • Patients are carefully screened preoperatively f o ensure only healthy patienf s with probable hernias are invited fo äffend (via a questionnaire, and with the surge of information technology, this can now be pertormed online) • Patients are active participants in fhe service

' Because it has targeted a single, specific type of patient—i.e, patients with no major medical co-morbidities and in good health—it has avoided the need to add costly equipment in the diagnostic and therapeutic fields of medicine delivery process (during examinafion and hernia confirmation), especially in light of local anaesthetic procedures where fhe pafienf can gef involved • There are reduced costs in terms of nursing care peri-operatively, housekeeping and laundry, because everyfhing is planned appropriaf ely and if is very rare for things to deviate from the plan. It is also important to note thaf Shouldice also boasts a high customer and staff satisfaction rate, while simultaneously providing a renowned surgical service at an affordable price (Shouldice, 2013).

Carpal tunnel treatment centre
Every viable business model starts with a value proposifion—a producf or service fhat helps customers do more effecfively, affordably and conveniently a task thaf fhey would like to complefe or goal fhey would like to achieve (Markefing Science Insfifufe, 2010). The postulated CTTC can be designed as a centre for: • The confirmation of CTS diagnosis • Subsequent surgery • Post-operafive physiotherapy. CTS diagnosis (clinically by a surgeon), with or without nerve conduction studies, and subsequent open surgery can be pertormed in a single day clinic visif, as has recenfly been reported (Ball ef al, 2on). The unique selling point for the CTTC would fhus be multi-fold: if would provide a dedicated centre for open carpal

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Surgery for CTD can be open, or endoscopie. The most commonly performed technique is open surgery at this moment in time, involving a longitudinal incision in the midline ofthepalm/uyrist tunnel release, in addition to the other benefits ofthe surgical experience, while maintaining the Shouldice operating concept. By optimally integrating the entire process, from preadmission preparation to the surgery process and subsequent rehabilitation and discharge, this value-adding process can substantially reduce CTTC costs, vrith much higher levels of quality, as Shouldice has shown us. For example, carefully designed questionnaires can be sent to potential patients prior to appointments being made—these would address particular questions targeting CTS symptoms and signs. If the diagnosis of CTS was likely when screened by a surgeon, or already confirmed when the referral was made, and surgery is therefore warranted, then these patients would be suitable candidates for attendance. On arrival at the CTTC, patients could foflow the same process structure/assembly line of Shouldice in to maximise efficiency. For example, this would include the waiting room phenomenon (where patients are initially prepared before they are 'seemingly whizzed' through the day's events to come), followed by a swift and thorough carpal tunnel/hand examination and referral for nerve conduction studies if appropriate. Those patients with no evidence of CTS would be rejected and their pathway would end, while those with confirmed CTS would be referred to the payment section, culminating in surgery that same morning or afternoon, and ending in referral to physiotherapy post-operatively (Heskett, 2003). In light ofthe initial specialised questionnaire screening process (aiming to accept patients who are likely to require surgical decompression to relieve their symptoms), it is assumed that
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the majority of patients who arrive at the CTTC would be surgical candidates, who may or may not have already experienced conservative measures including sphnting and steroid injections previously. Only a minority would be rejected—albeit rarely—if their diagnosis was either unclear or rather complex, requiring further assessment elsewhere. It must be mentioned that surgeons differ on opinion with regards to the requirement for nerve conduction studies to confirm diagnosis of CTS. For example, the previous British Society for Surgery ofthe Hand guidelines (which are currently being reviewed) stated that nerve conduction studies 'are usually reserved for equivocal diagnoses and are not required routinely', and suggested specific examples (clinical and medico-legal) where nerve conduction studies would have been indicated (British Society for Surgery ofthe Hand, 2013). The American Academy of Orthopedic Surgeons (2007), however, recommends nerve conduction studies to be performed 'if clinical and/or provocative tests are positive, and surgical management is being considered'. Within the CTTC setting it is proposed that nerve conduction studies are performed for every patient (unless they are referred with positive studies), so as to standardise diagnosis and management. Surgery for CTD can be open, or endoscopie (Patil et al, 2006). The most commonly performed technique is open surgery at this moment in time, involving a longitudinal incision in the midline ofthe palm/wrist. It is an operation that plastic surgeons, neurosurgeons, and orthopaedic surgeons currently perform. In contrast to groin hernia repair, surgery for CTS does not require post-operative admission; patients can go home post-operatively as carpal tunnel decompression is a day-case procedure (Patil et al, 2006) with no effect on mobilisation (unless the patient uses a walking stick to get around because applying such pressure on to the operative site is contraindicated, but these patients would be 'screened' with the pre-operative questionnaire and targeted post-operatively). It is important to address the psychological and physical needs—where

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necessary—of these patieuts to help speed their recovery aud returu to work. What CTTC cau offer post-operatively is au intensive physiotherapy teachiug sessiou, re-euforced with leafiets aud poteutial videos, supported by au onliue website, so that patieuts are prepared for their post-operative recovery pathway. This will iuclude geutle mobilisatiou aud scar massage at the two-week time frame. As part of their rehabilitatiou programme, techuical aud psychological preparation—for example, that they may be uuable to enjoy particular activities till the wouud has healed aud the haud is paiu-free—help improve the success of their experience. This maybe especially useful for those patieuts that feel they have progressed well post-operatively aud do uot ueed to seek medical atteutiou, particularly if the atteudiug the CTTC requires a fair amouut of travelliug. As part of streamliuiug the process, a six-week post-operative check-up cliuic cau be held at a specific time for those patieuts that prefer to be seeu iu hospital at the six-week time period to iucrease customer loyalty aud diaguose early post-operative complications for those that live close-by. This cau be structured into the assembly Hue as a moruiug cliuic; this cau be uurse-led which is safe aud cost-effective (Newey et al, 2006) freeiug up surgical resources so as uot to disrupt the proposed assembly liue. Giveu the supportive euviroumeut at Shouldice amoug staff, aud fosteriug a similar euviroumeut at CTTC, uurses could discuss complex cases with surgeous, if this were to be implemeuted. There are of course, mauagerial elemeuts iu the service system to support the Shouldice service coucept; these cau also be adopted at the CTTC. Surgeous aud uurses v«ll require careful selectiou aud will ueed to uudergo rigorous traiuiug to iuclude uou-techuical skills—maiuly commuuicatiou aud team-workiug—which are crucial to the success of a team-based approach, iu addition to improved patieut satisfaction aud perceived quality of care (Norgaard B et al, 2012). By fosteriug a family-like ambieuce, surgeous aud uurses cau also observe aud advise oue another if required. Furthermore, the CTTC cau eveu arrauge reuuious every

Drivers fi)r change to healthcare delivery include quality, hospital efficiency and enhanced patient experiences. Alterations in the provision of healthcare must be accompanied by a direct improvement in the quality of its provision. patieut feedback to farther optimise the CTTC experieuce, streugtheuiug customer loyalty aud positive word-of-mouth advertisemeut. Shouldice Hospital offers acres of laud, to eucourage patieuts to walk arouud iu beautiful, uatural surrouudiugs. Certaiuly acres of laud are uot required at the CTTC, which would ideally operate as a day-case ceutre, aud so it may be prudeut to have several 'couveuieutly-located' centres iu major cities. Shouldice Hospital is located uear a large city airport, which gives it access to a worldwide market, iu additiou to its local populatiou. Furthermore, giveu its curreut fixed capacity of 89 beds, improved capacity use has been a hot topic—however this is beyoud the scope of this review. Bed requiremeuts would uot be au issue for the CTTC due to its day case nature, aud so speudiug ou other facilities such as the quality of waitiug rooms aud activity rooms may be far more important. A receut study has shovra that psychosocial factors explaiu a uotable proportiou of the variatiou iu paiu iuteusity aud disability affer miuor haud surgery (Vrauceauu et al, 2010). Improviug the patieut jouruey should also be a goal of the CTTC. It has beeu shown that preoperative auxiety cau be reduced by exposure to music (Mitchell, 2003). Furthermore, it has also recently beeu showu that there may be a role for music iu reducing iutra-operative auxiety levels iu patieuts uudergoiug miuor surgery while awake, where easy-listeuiug aud classical music were well-tolerated by patieuts (Sadideeu et al.
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3 I I î o o other year to keep alumui iuformed aud gather
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One of the things Toyota taught the business ujorld is that by standardising the production line, we are able to continuously improve and respond to unanticipated problems in predictably effective ways.
2012). This is an important consideration in terms of future building planning so that systems can be incorporated into the overall design. It must be noted, however, that there may always be objections to the development of such a dedicated facility. The first is that such a value-adding process hospital cannot handle medical emergencies and so without on-call medical emergency staff (from other specialities), patients will have to be transferred to the closest appropriate unit. This may reduce the overall effectiveness of such units. However, it is extremely rare for a patient undergoing local anaesthetic CTD to suffer a medical emergency that requires transfer. The second is that such specialist hospitals are accused of 'cherry picking' the youngest, healthiest and most profitable patients, while the sickest patients typically go to the general hospitals. Nevertheless, this certainly does contribute to the success of Shouldice hospital. On another note, the CTTC may attract skilled surgeons who want to be part of a success story involving a known surgical caseload and comfortable (non-existent) on-call system, and hence lifestyle. However, there may also be excess demand by those surgeons who are currently staff grades within the NHS, who would like to participate in such surgical roles as part of the CTTC. This is important given documented reduced opportunities for progression in the current UK surgical climate, due to a mismatch in admission to core surgical
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training and higher specialty training (Oxtoby, 2010). There is a surplus of surgeons with a background in a number of surgical specialities such as neurosurgery, plastic surgery and orthopaedic surgery, who afl perform CTDs, unable to progress in their chosen specialty. Such surgeons, some with a vast amount of surgical experience, may be ideal candidates for taking up roles. With expert guidance, and self-deliberate practice, expertise can be achieved, allowing them to perform CTDs to expert standards (Ericcson, 1996; Sadideen et al, 2013).

Conclusion and future approaches
Drivers for change to healthcare delivery include quality, hospital efficiency and enhanced patient experiences. Alterations in the provision of healthcare must be accompanied by a direct improvement in the quality of its provision. One of the things Toyota taught the business world is that by standardising the production line, we are able to continuously improve and respond to unanticipated problems in predictably effective ways. On the contrary, executing a task differently every time, we are subjected to greater difficulties making it harder to improve. Shouldice Hospital prides itself with an innovative value proposition and strategic service concept, making the patient an integral aspect of the treatment pathway, both as part of the multidisciplinary pre-operative admission process and emphasising the importance of post-operative mobilisation and integration with other patients, making the Shouldice experience unique. Furthermore, Shouldice demonstrates an excellent example of a focussed, well-developed service delivery system, providing the patient with high-quality and low-cost surgery, and in particular with the durable, reputable Shouldice technique. Shouldice also capitalised on a specific market segment, catering for that small niche of healthy patients with hernias. The CTTC can potentially be modelled on Shouldice concepts. Open CTD is generally a straight-forward operation, and so by developing a dedicated unit, healthcare professionals can excel in providing this service to patients. The key difference is that patients undergoing CTD do not require overnight admission, and so
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the resources and costs involved in designing inpatient stay are unnecessary, but would be spent in other areas (after appropriate market research) to optimise the patient journey. The post-operative assembly line structure may also be unique. There is an abundance of patients with CTS awaiting CTD, and given a change in the political agenda to healthcare priorities and a reduction in training progression opportunities, demand may exist for a CTTC by patients and surgeons. Its success would depend on extensive planning and careful execution with a team-based approach. In the future, there may be a role for advancing into a world renowned endoscopie surgery CTTC, allowing it to develop with time and expertise. Current data suggests that open CTD has lower complications (Thoma et al, 2004) but with the advent of technology, experience and patient preference (for minimally-invasive surgery), there may be a role for its incorporation. Providing an endoscopie option does pose the risk of increased cost (of purchasing, using and maintaining), and so its cost-effectiveness will need to be taken into account prior to its implementation, ensuring patient safety is prioritised at all times. The CTTC is currently a single postulation based on the Shouldice model. With diversification and grov^rth, other hand conditions may also potentially prove appropriate, such as intervention for Dupuytren's disease, although the model would need to be modified to cater for other crucial factors e.g. the different type of anaesthetic (regional block vs. general anaesthetic), surgical vs. non-surgical options (open fasciectomy vs. collagenase injections in the case of Dupuytren's) and the different postoperative rehabilitation programmes required for different types of hand surgery (post-operative Dupuytren's surgery requires regular hand therapist assessments, exercises and splints). Further exploration of other markets (e.g. ophthalmology, such as cataract surgery) and feasibility studies would need to be conducted beforehand. Perhaps such approaches to efficient healthcare delivery can enhance our clinical effectiveness whilst stimulating diversification and encouraging competitive, optimal practice;

KEY POINTS
I Optimal healthcare delivery in a cost-effective manner while achieving profitable outcomes requires careful planning and execution I The Shouldice model is a clear example of the concept of a highly innovative value proposition I Optimisation of the patient 'journey' (experience and satisfaction) remains key throughout I We can learn vast amounts from the Shouldice model, and use it as a basis to apply to other settings, such as that of the proposed carpal tunnel treatment centre I It is important to further explore and capitalise on such knowledge to improve our service to patients and doctors, particularly in light of restructuring of the national health service and reduced training opportunities

I

it may also prove useful for the healthcare job market by attracting highly skilled surgeons who chose not to wait to progress within the NHS. IHHWBI

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