Advice on Creating and Maintaining a Successful Bariatric Practice

| June 12, 2012

Part 1
Ascending to Accreditation

by Jama Stinnett, LPN, CPHQ
Ms. Stinnett is the Office Manager, New Life Center for Bariatric Surgery, Knoxville, Tennessee.

Bariatric Times. 2012;9(6):22–26

Funding: No funding was provided.

Disclosures: The author reports no conflicts of interest relevant to the content of this article.

Ascending to Accreditation

Charles Dickens began his classic, The Tale of Two Cities, “It was the best of times, it was the worst of times.” Just as this story begins, so will yours as you create a bariatric program.

A successful bariatric practice cares for bariatric patients under a plan that implements set criteria focused on providing the best possible patient care and outcomes, and the lowest possible complications.

ACHIEVING ACCREDITATION
The creation of an accredited center is a bumpy road that requires not only data collection, criteria-driven protocol implementation, and designation but also a willingness of the center’s team members to put it all into action. The true beginning of success is a vision for your center. The vision, in some form, will be of a place that will lift patients to their best opportunity for recovery to good health.

Is your vision an imposing building on a hill with covered entrance and columns? Or perhaps it is a friendly inviting place where patients feel they become a part of a caring family. Another vision may include a polished clinical environment that instills trust in expertise from the waiting room to the exam rooms. The fact is there are many ways to envision and achieve accreditation, but you first need to develop your own vision for a place that is committed to delivering the best care to a community of patients that have likely not always received such thorough care.

WHY SEEK DESIGNATION?
A bariatric center may be reviewed and designated by one of many different organizations. and private payors offer designations. Both professional organizations and private payors offer designations.

Professional organizations. Professional organizations offering designations include  the American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgeons (ACS) who accredit jointly through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBS AQIP).

Also, most private third-party payer organizations designate particular practices for their own community of patients and for their own reasons.
Four very important reasons for seeking and meeting designation criteria are as follows: 1) to ensure excellence in the care you give, 2) to maintain competitive equivalency with your peers, 3) to improve access for your community’s bariatric patients, 4) to get paid for your work. In order to achieve all of these goals, you will likely need to apply for designation from multiple organizations.

While almost any one professional organization designation satisfies the first two reasons, the need for multiple designations arises since being certified by one organization is not necessarily accepted by another payer. I recommend choosing the payers that represent the top 80 percent of your revenue or payer mix to identify the most important designations for your program.

ELEMENTS OF A SUCCESSFULBARIATRIC PRACTICE
As we examine all the elements needed for a succesful, accredited bariatric practice, you will recognize the repeating theme that success in each element comes from the top down. Modeling leadership to inspire the team, sharing the vision, and defining the reality will create leaders among your team and success in your center. As you plan each element for your program, remember that the leaders must set the bar and model the expected standard.

Leadership. Leadership is the first and most critical element for success. The surgeon must be the captain of the ship. No surgeon can abdicate this role regardless of whether your program is hospital system owned, a true cooperative between hospital and physician practice, or an office-based program. Without strong physician involvement and leadership, the multidisciplinary team will not find the vision, be engaged, know the expectations, or feel accountability. The beginning of the program is an excellent time for investing in your leadership skills. In his book, Hardwiring Excellence, Quint Studer points out that we would consider an untrained clinician providing care to be malpractice and so we should consider not investing in leadership development to be the equivalent of organizational malpractice.

What your center’s reality will become and what you need to arrive in that place is a set of expectations that is communicated, planned, and followed with precise accountability measures. No team can meet the expectations of the vision if they do not know the expectations and do not have the resources to achieve them. Although a multidisciplinary team may achieve near self direction, accountability to the leader is the apparatus that motivates stability.

You must guard against the pitfalls that beset a leader and; therefore, his or her vision. Lack of time is the enemy and the failure to give your team time is the most eminent threat to achievement. Make your priority to build in regular times for the team to meet with the surgeon. In these meetings, include discussions on upcoming cases, postoperative issues, program advancement, and processes. The surgeon’s council, renewed challenges to the team and commendation are the key to maximizing the team’s engagement.

Marketing. It might seem like the cart before the horse to think of acquiring patients before your center is crafted, but creating a bariatric program is a multi-dimensional project. Timing is important and requires planning because the process for patients is a long one. If you do not conceive and implement your marketing early on, you run the risk of creating a well-crafted program that sits empty for 6 to 8 months as patients work their way through the 6- to 8-month process of obtaining approval and preparing for surgery.

Getting the word out to prospective patients and figuring out how to differentiate yourself from other programs in your area are important factors in how you proceed. You also need an understanding of how and where to reach potential patients.

Patients must first learn about the fact that weight loss surgery exists as a possibility for them. Then, they begin to research how and why it works and what it involves. The computer age has given patients the ability to research healthcare as never before and many patients learn a great deal about bariatric surgery before deciding to pursue it themselves. Once they edge closer to pursuing bariatric surgery, they seek the advice of those they trust. Friends and family will be an important referral source in later stages but you will not experience significant impact from this resource until after you have completed about 1000 cases, at which point, you will notice a shift toward this referral source. In the beginning, you will find that patients come to you because they have asked the advice of their primary care physicians (PCP). Usually, this inquiry happens only after the patient has thoroughly researched the treatment on his or her own and brings up the subject to their PCP. Fortunately, there is a growing trend among some specialties and PCPs to refer for weight loss surgery. So, this referral source has become even stronger and can also be improved by your program’s ability to offer education to the PCPs in your area.

So how does the process of patients exploring weight loss surgery impact your marketing strategy? You need to have some exposure at every step of the way. Widespread name recognition broadcast through different media outlets, such as TV, radio, and billboards, are expensive and might capture patients not yet ready to commit to the weight loss surgery process. Whatever the expenses in advertising your center, you still need to get your name out there and stir these initial inquiries or someone else will.

Web advertising is an important venue since bariatric patients almost always research weight loss surgery on the internet. This resource is becoming more important in the patient acquisition arena. Your website and its maintenance is the second most critical media outlet and should be near the top of your attention in marketing your center. Making sure you have an experienced web designer that knows how to create and consistently optimize your website will be well worth the money.

Editor’s Note: For specific guidelines on choosing a medical website provider for your center, don’t miss Part 2 of this installment entitled “10 Questions to Help You Choose the Best Medical Web Provider for Your Practice,” in the July 2012 issue of Bariatric Times.

Following up on your marketing impact is also of utmost importance. For instance, when a patient contacts your program (or when they come in for a first appointment), you may want to ask them how they heard about your program (e.g., website search, magazine ad, billboard, word of mouth, referral). Good tracking of referral information on each patient allows understanding of where referrals originate. This tracking information is critical to the adjustments in your marketing expenditures. This is something your program cannot do without.

The staff members should be well rehearsed in relaying key information to a potential patient and properly prepared to answer questions and schedule appointments. In medical practices, surgical programs, and other healthcare arenas, a good plan can be sabotaged by lack of accountability, tracking, and rapid response to the information. This is an even greater danger for programs based within large hospital systems where decision making maybe slow and bound to countless meetings and committees. To avoid this danger, formulate your program with a streamlined decision-making process so that you can react to the changes in your community and to the information you collect.

Lastly, it is important to remember that when a patient makes the momentous decision to pursue bariatric surgery, for them, a clock starts ticking and he or she will likely want to get started right away. Frequently placing newspaper ads with information about your center can be another great way to reach potential patients. The previously mentioned marketing strategies combined with strong relationships between your program and PCPs will help you get prepared and eligible patients to seek treatment at your center.

Service. The criteria set by your designating body or bodies will drive your plan of care. Review the criteria that you need to meet and make sure as you plan your processes that they consider the following few basic foundations.

Consistency. Standardize everything from the front door to the back door. Create a care plan that starts with the patient’s first contact to your program and ends no earlier than 12 months after surgery. Encompass the hospital care plan and make sure your standard orders reflect the care plan’s content. The entire care plan will cover how you interact with the patient and other needed services for the full plan of care, including your patient’s hospital stay and postoperative care.

Documentation. Leaders often experience a time when they have made an effort to create and implement a process only to later find that people are no longer adhering to it.

To ensure that your program does not fall prey to this phenomenon you should document everything and be sure that your process, forms, checklists, and accountability measures protect the processes.

Tracking. Whatever first step you schedule for the patient, seminar, regular visit, screening visit, or referral to other medical services, you should start your tracking at the first contact. The bariatric pre-surgical process is long and patients may become discouraged. Ensure that your system has points of contact with the patient at least every two months. During pre-surgical processes, such as gathering records, undergoing screening tests, obtaining medical clearances and insurance-mandated medically supervised diet programs (if they are attending through another provider), make sure you encourage and prompt your patients to stay on track. Failure to follow up with patients may permit loss of motivation that is needed to get through insurance road blocks or interruption of the process by other life events. Investing in staff and processes that compel interaction with the patient will decrease time needed to surgery and increase the percentage of patients that you pull through from initial contact to surgery.

Education. Education minimums will be outlined in the criteria you are trying to follow but your team should strive to go beyond the minimum. Education for both the hospital staff and the patient will ensure that both your program and the patient can best deal with their responsibilities as a part of the team. Involve the physicians in staff training, set up a standard education required before a staff nurse can be assigned a bariatric patient, dedicate care teams in all areas of the practice, and do not forget staff that will not see bariatric patients often, such as staff in the intensive care unit and emergency room. Consider offering a specialized training to any staff who may be unfamiliar with caring for the patient population with obesity. It may also be helpful to provide reference manuals and access to the bariatric floor staff for questions and guidance. Only when everyone is prepared to carry out their responsibilities can there be program success. The opportunity to manage both the staff and patient expectations ensures that your program will project the quality care you are providing.

Multidisciplinary team. “Multidisciplinary team” is likely a term with which you are familiar. The concept that many disciplines are needed for support and success in the care of the surgical weight loss patient is not new. Requirements for specific team members (e.g., certified bariatric nurse or data entry specialist) may be included in the requirements of your designating bodies criteria so be sure you review this carefully before committing critical positions.

This is another area where leadership, education, and experience can make a substantial distinction in your program. The ability to creatively plan staffing models and effectively select and develop staff and keep them engaged and motivated is invaluable in your programs success.
There may be temptation to take an existing quality employee and build a position around this person, but it is important to also consider the set of tasks to be performed and assess what types and numbers of team members are needed. Consider not only what disciplines are needed to support the patient, but also what disciplines can be used to improve efficiency in your program. Through selection of staff members with multiple skills or credentials, you may improve your ability to offer services without requiring a staff member for each task.

For example, you might seek out a nurse who is also a licensed x-ray technician if your program will offer band adjustments under fluoroscopic guidance (Note: each state has its own rules that govern who can run a C-arm machine and they vary greatly so do your research). Many program leaders may not feel they can start out with a full-time exercise physiologist but an exercise physiologist may also have training and or experience in providing educational programs, motivational presentations, data management, and tracking. All of these skills fit in to your plan and may allow you part-time access to an exercise professional while he or she fulfills other needed roles. Your team is your program, so consider its members carefully and do not be afraid to review your staffing model frequently to get the most benefit for your program and its patients.

CREATION THROUGH CHANGE
Martin Luther King, Jr. once outlined four components needed for change: collection of data, negotiation, self purification, and direct action. Dr. King applied these concepts to create change in the way a people was perceived and cared for. I find there are parallels to the mission of providing care for the bariatric patient. These previously underserved patients have begun to benefit from the changes and improvements that designating centers brought about and these concepts hold true.

FINAL THOUGHTS
To construct a successful, accredited bariatric practice, you first must collect data, know your facts, study every facet of the criteria, and educate all who will participate. Second, you must negotiate with many partners to achieve an effective, like-minded multidisciplinary team within a healthcare system. Third, you must seek self purification. Be clear in your vision and dedicate yourself to its realization. Lastly, you must take direct action. Your actions, whatever your role in implementing a successful bariatric practice will bring you great satisfaction and purpose.

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