Citizens Bariatric Center, Victoria, Texas

| May 2, 2007

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TELL US ABOUT THE ROLES AND RESPONSIBILITIES OF THE LEAD STAFF AT YOUR FACILITY.

The lead staff at Citizens Bariatric Center consists of two full-time bariatric surgeons and a nurse coordinator. There are many departments with individual directors, all of whom are members of a multidisciplinary team that meets on a monthly basis. These include psychotherapy, dietary, exercise, OR, ICU, ER, continuing education, quality management, and marketing.

The entire program is under the directorship of bariatric surgeon Dr. Dean McDaniel. He communicates directly with the various department leaders, overseeing the development, growth, and day-to-day operations. Dr. Craig Chang, also a bariatric surgeon, serves as the assistant director with responsibilities of clinical research and data collection. In addition, he directs support group activities in multiple cities. Nanette Berger, RN, is the bariatric nurse coordinator responsible for patient care concerns. Her primary duties include staffing the bariatric center with well-educated nurses experienced in bariatrics, overseeing procedural guidelines for all patient care departments, accreditation issues, and public relations.

WHAT IS THE SIZE OF YOUR FACILITY? WHAT DOES IT PHYSICALLY ENCOMPASS?

Citizens Bariatric Center is a division of Citizens Medical Center, a 344-bed acute care hospital. Centrally located between Houston and San Antonio, the center serves all of South Texas. The bariatric wing, located on the top floor, is composed of 21 spacious, private rooms specifically designed with the obese patient in mind. This floor is equipped with classrooms and consultation rooms for discussions with patients and families. A large central classroom is used for seminars and support group meetings. There are two bariatric operative suites with state-of-the-art equipment, including a central control station, flat screen monitors, and ceiling booms. Located off campus, the center has a modern exercise facility with aquatic and aerobic classes as well as weight training and an indoor track. Multiple classes are designed for bariatric patients only. This facility also serves as the headquarters for the annual “Walk from Obesity.”

The outpatient clinic is located immediately adjacent to the hospital in the professional office building. This 3,500 square foot building has eight patient rooms and multiple offices. Here surgeons and staff evaluate new patients and provide postoperative care. The waiting area and exam rooms are all equipped with oversized furniture. Insurance issues and scheduling are handled in this office as well.
Please describe your staff.

There are four surgeons associated with Citizens Bariatric Center: Dr. Dean McDaniel, Dr. Craig Chang, Dr. Stephen Hougen, and Dr. Reuben Koenig.

Dean McDaniel, DO, is Chairman of the Bariatric Department and Program Director. He is a full-time bariatric surgeon who served as Chief of Surgery for Citizens Medical Center from 2000 to 2004. A graduate of Oklahoma State University, College of Osteopathic Medicine, Dr. McDaniel is board-certified in surgery. He is an active member of the American Society for Bariatric Surgery (ASBS) and a designated “Center of Excellence” surgeon. Dr. McDaniel began performing laparoscopic gastric bypass procedures in 2000. To date, he has had no conversion to open cases. In addition to patient care, he is responsible for credentialing issues and directing the various departments of the center.
Craig Chang, MD, FACS, is a fellowship-trained bariatric surgeon specializing in laparoscopic gastric bypass and adjustable banding procedures. While serving in the military, he developed a special interest in bariatric surgery. He joined Citizens Bariatric Center in 2003, following fellowship training at the University of Texas Southwestern. He is responsible for directing support group activities and data collection. Dr. Chang has recent publications in the field of bariatric surgery, and is board-certified with the American Board of Surgery and an active member of the ASBS. He is also a designated “Center of Excellence” surgeon.

Stephen T. Hougen, MD, FACS, is a graduate of the University of Texas Health Science Center with board certification with the American Board of Surgery and fellowship training in vascular surgery under the direction of Dr. Michael DeBakey. Dr. Hougen continues to perform other procedures in addition to bariatric surgery. He currently serves as the Trauma Director for Citizens Medical Center, where he has been an active staff member since 1985.

Reuben E. Koenig, MD, FACS, is a graduate of the Baylor College of Medicine. Dr. Koenig has been an integral member of the surgery staff at Citizens Medical Center for 30 years. He has recently limited his practice and serves as the primary assistant in bariatric procedures, allowing both full-time surgeons to operate simultaneously.

Another key member of the bariatric team is Nanette Kolu Berger, BSN, RN, who serves as the nurse coordinator. She is extremely active in promoting bariatric surgery to the public and medical community. Berger is a member of ASBS and is currently serving as a member of the “Practice Analysis Task Force,” developing the certification exam for bariatric nurses. Ron Herrmann, PA-C, is the physician assistant working closely with the surgeons. Others include Sandra Vela-Cisneros, clinic manager, Jami Martin, RD, LD, bariatric dietitian, Amanda Havelka, insurance coordinator, Jennifer Burns, LVN, outpatient nurse, Marcy Villarreal and Mary Joy, scheduling coordinators, Terry Guerrero, bariatric public relations specialist, Paul Primm, LMFTA, and Cheryl Green, LPC, counselors, and a host of dedicated staff in both the outpatient and inpatient departments.

What is the number of patients treated on an annual basis at your facility? What are the patient demographics?

On average, our surgeons perform 300 primary laparoscopic bariatric procedures a year. Revisional surgery is performed on a select basis. A typical demographic breakdown of our patient population is 85-percent female, average BMI is 47, mean age is 44, 80 percent are laparoscopic gastric bypass, 15 percent are laparoscopic adjustable banding, and five percent are open or revision.

How is your facility managed and by whom?

Citizens Bariatric Center is managed by David P. Brown, CEO, and the Board of Directors of Citizens Medical Center.

Does your center have one particular area of expertise?

Our center goes the extra distance to treat all aspects of obesity, understanding this is a complex, multifactorial disease. Both before and after surgery, patients receive a detailed treatment plan for behavioral and environmental change. Staff members direct them to moderated group therapy meetings, mentors, accountability partners, and bariatric exercise programs. Guest speakers are arranged for monthly support gatherings. There is additional communication via the website (www.citizensbariatric.org) and newsletters. To increase compliance, groups are organized in multiple cities. We also offer a 12-week program for behavioral relapse.

Dr. McDaniel and Dr. Chang continue to perfect the laparoscopic Roux-en-Y gastric bypass with amazing results. There were two mortalities in the first 500 patients and there have been no deaths or major complications since, with an average length of stay under two days. This is attributed to a standardized approach with trained bariatric scrub techs and nurses. Technical aspects include linear staple connections with hand-sewn closure and oversew. All mesenteric defects are closed. The average operative time is 90 minutes.

GIVE A GENERAL SYNOPSIS OF HOW YOUR PATIENTS ARE TREATED WHILE UNDER THE CARE OF YOUR CENTER.

Patients often attend a free educational seminar before consultation. A screening application is reviewed, and appropriate candidates are directed to a scheduling coordinator. This person will create an itinerary for the patient involving a dietary education class, psychological evaluation, group therapy, lab/x-ray tests, physician assistant assessment, and surgeon consultation. Upon approval of surgery, patients will meet a second time with their surgeon to answer questions and complete registration.
While at the center, patients are treated with the utmost dignity by the entire staff, from the attending surgeon to the nurses and housekeepers. We are extremely gentle with our obese patients, who have grown accustomed to a life of ridicule and failure. Our small-town family atmosphere conveys a feeling of comfort and hope.

WHAT ARE SOME OF THE DEVICES INTRODUCED AT YOUR FACILITY LATELY?

We are currently studying a technique to perform laparoscopic procedures without stationary liver retraction. Our center is now using body composition analysis via bioimpedence as a method to evaluate the quality of weight loss.

HOW IS INVENTORY MANAGED IN YOUR FACILITY? WHO HANDLES THE PURCHASING OF EQUIPMENT?

Surgical inventory is managed by the OR Director, Dot Hayes, RN. Requests for patient care supplies are under the direction of the bariatric nurse coordinator, which then filters through the purchasing department. New equipment purchases are evaluated by management and staff for need and cost-effectiveness.

HAS YOUR FACILITY RECENTLY EXPANDED IN SIZE AND PATIENT VOLUME? WILL IT BE EXPANDING IN THE NEAR FUTURE?

Our non-physician staff continues to grow at a steady rate. A satellite outpatient clinic was recently opened in neighboring Corpus Christi. While still relatively new, the surgical office space and bariatric wing were designed with room for considerable growth. Most of our current expansion involves additional support groups in cities across South Texas.

HOW HAS MANAGED CARE AFFECTED YOUR FACILITY AND THE CARE THAT IT PROVIDES TO PATIENTS?

At Citizens Bariatric Center, we attempt to work with all healthcare plans to allow affordable benefits to those that need it. Despite increasing data showing the cost effectiveness of weight loss surgery, more carriers are writing policies with absolute exclusions. This does not appear to be a managed care issue per se, but rather a statewide insurance problem. Other plans are choosing to continue coverage with lengthy prerequisite medical treatment requirements. Our self-pay volume has increased, as has our Medicare volume since Center of Excellence designation.

What measures has your facility implemented in order to cut or contain costs and improve efficiency?

Clearly, the most cost-effective measure at our center is a standardized operative approach with the linear stapling device. All suturing is performed with a hand sewn technique, avoiding the costs of suturing devices. We have not found an indication for the use of strips or glues in primary procedures. Patient care pathways are utilized outside the OR with minimal postoperative tests and medications. The average length of stay is less than two days.

DOES YOUR FACILITY HAVE AN OUTPATIENT PROGRAM?

Outpatient surgery is evaluated on a case-by-case basis. We are finding more and more that patients are suitable for this type of care with gastric bypass or adjustable gastric banding.There are many outpatient programs involving other disciplines within our center. Dietary education, group therapy, and bariatric-specific exercise are just a few of these programs. Our surgeons maintain a lifetime commitment to all bariatric patients.

HOW DOES YOUR FACILITY DEAL WITH THE ISSUE OF PATIENT SAFETY AND STAFF SAFETY?

We have appropriate bariatric furniture and equipment. There is a patient safety committee that establishes protocols for transferring patients. Our departments are adequately staffed to reduce the risk of injury.

HOW ARE EMPLOYEES ORIENTED AND TRAINED AT YOUR FACILITY?

All new employees attend a general orientation program before receiving specific training in bariatric care. Sensitivity and proper ergonomics are emphasized in training organized by the bariatric nurse coordinator. New employees are allowed to observe a bariatric procedure and rotate through other departments.

HOW IS STAFF COMPETENCY EVALUATED?

Citizens Bariatric Center staff members receive a competency/skills checklist when they are in orientation. They work with an accomplished preceptor for three months with ongoing skills assessments during this time. Employees are then evaluated on an annual basis.

PLEASE DESCRIBE YOUR PATIENT EDUCATION PROGRAM.

General information is provided on our website. Patients are encouraged to attend a detailed free educational seminar. Before surgery, patients are required to attend a dietary education class and at least one group therapy session. At preoperative registration, patients are asked to complete a test evaluating their knowledge about bariatric surgery. Any wrong answers are discussed with the patient. Support gatherings invite guest speakers each month with some area of expertise pertaining to bariatrics.

WHAT TYPE OF PATIENT SUPPORT PROGRAMS ARE OFFERED AT YOUR FACILITY?

Our primary support group is open to all bariatric patients and guests. The group is known as “Pouch Pals.” They gather once a month to hear guest speakers lecture and patient members tell their stories. Group members are available to serve as mentors for new patients.

The program is under the direction of our public relations specialist and Dr. Chang. Support is also offered through group therapy meetings moderated by our licensed counselors and internet groups.

DOES YOUR FACILITY USE ANY ALTERNATIVE THERAPIES?

We strongly encourage patients to seek help for underlying eating disorders with programs such as 12-step groups and therapy. Our mentoring program has patients working together to hold each other accountable with behavioral change.

WHAT QUALITY CONTROL ASSURANCE MEASURES ARE PRACTICED IN YOUR FACILITY?

Outcomes are tracked through our Quality Management Department. This information is discussed at the multidisciplinary meeting and Surgery Department meetings.

WHAT TRENDS DO YOU SEE EMERGING?

Bariatric centers across our nation seem to share a common concern about the growing epidemic of obesity. With effective surgical treatments in place, the future should bring more efforts for early intervention and prevention. Medical treatment programs for mildly obese individuals are gaining popularity, as well as minimally invasive options for the 30 to 35 BMI range.

What makes your facility unique?

The holistic relationship that we foster with our patients is what makes Citizens Bariatric Center unique. We are committed to their long-term success. After surgery, our patients aren’t just encouraged to attend support groups; we make it happen for them. We offer group therapy three times a week locally and with other groups regionally. We sponsor reunions and walks annually. Our patients become part of our program by speaking at support meetings and mentoring to others. There are support groups specifically held for behavioral relapse. Our groups are facilitated by licensed moderators. It is truly a small-town family atmosphere.

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Category: Bariatric Center Spotlight, Past Articles

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