Taking Bariatric Safety to the Next Level

| October 13, 2014

by Philip R. Schauer, MD; James W. Saxton, Esq; and Amanda R. Budak, RN, CBN, PhD

Dr. Schauer is Director of Bariatric and Metabolic Surgery and Director of Minimally Invasive Surgery at The Cleveland Clinic. He is a past president of the American Society for Metabolic and Bariatric Surgery and is a leading physician quality and safety champion. Attorney Saxton is chair of Stevens & Lee’s Health Care Litigation and Risk Management Group, and Co-Chair of the Department of Health Law. He is a trial lawyer with over 30 years of experience, defending surgeons and hospitals in the courtroom. Dr. Budak is Executive Director of SE Healthcare Quality Consulting. She has over 22 years of healthcare experience with a focus on clinical effectiveness and risk management.

Funding: No funding was provided.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2014;11(10):16–17.

ABSTRACT
Bariatric surgery continues to be a proven treatment for significant weight loss in the morbidly obese population. While the safety profile continues to improve, there is still a high incidence of medical malpractice claims. This article provides strategies for improving patient safety and decreasing liability exposure.

The statistics are disturbing: one in every two bariatric surgeons will be hit with a medical malpractice claim during their career.[1] The cost of fighting those claims is significant as it can cost thousands of dollars and two to three years or more in time to mount a defense, not to mention the emotional toll on the surgeon and his or her family.

Changing the Bariatric Risk Equation
With obesity continuing to rise, and an increase in bariatric surgery expected, new approaches to managing risk and reducing malpractice claims are needed. The good news is that the liability equation can be changed if bariatric surgeons adopt targeted risk-management programs, engage in ongoing medical education, and commit to even more outreach to patients to engage and manage their expectations.

While most surgeons recognize the urgency in finding new approaches to risk management and improving safety, the questions remain how best to implement such programs, especially within today’s reimbursement system.

Data’s role in bariatric surgery. Our surgical team has discovered that in the post-Affordable Care Act (ACA) environment, data are becoming more critical to risk-management endeavors, creating challenges in terms of knowing which data is relevant, but also providing many opportunities.

Desirable data to measure include the bariatric patient experience and certain clinical safety metrics. Endeavoring to improve scores on these measures will be important from a reimbursement perspective, and can also positively impact one’s professional liability exposure.[2–4] The ability to incorporate certain targeted strategies (with documented compliance) may help reduce the potential of a claim while enhancing a bariatric surgeon’s economics.[5]

Tips for using data to manage risk and improve safety. There are new rigorous standards in which payers and employers are holding healthcare providers accountable. There have also been significant advances in transparency, which give the marketplace the ability to determine who is truly providing the best results. In this age of consumerism, patients are also using these data to determine where to receive their care. To be successful in the current healthcare environment, consider the following:
1.    Double down on the bariatric patient experience. Every practice should be using a bariatric-specific patient experience survey. Relying on a hospital survey or a generic survey will not get you the information required to impact your patient and his or her family’s experience. It will not give you the data you need to negotiate, and there are strong data that show higher patient satisfaction ratings can reduce liability exposure, affecting the overall economics of your practice. A bariatric-specific patient experience tool is one of your basic management and quality improvement tools. It is cost effective and creates a data point critically necessary to excel post ACA.

2.    Bariatric clinical effectiveness. The new value proposition focuses on concurrently reducing the potential of a bariatric adverse event, enhancing clinical outcomes and effectiveness, and containing costs and efficiency. Start by making sure that you are incorporating important bariatric best practices. For example, many bariatric patients present for surgery with undiagnosed obstructive sleep apnea (OSA).[6] This can create a dangerous scenario postoperatively in the use of narcotic pain management that can contribute to the incidence of apnea and ultimately death.
In a study of 2,877 patients screened for OSA in an academic medical center, 81 percent of high-risk patients had no formal diagnosis.[7] A best practice is to formally screen all patients for OSA and ensure that appropriate therapies are provided in the postoperative phase to avoid a respiratory arrest and death. Not screening for OSA is now considered below the standard of care in this patient population.[6]
Measure yourself in the performance of safety measures in areas known to carry risk and challenge yourself and your team to incrementally improve. As an example, in our experience, the key drivers of claims in bariatric surgery are related to pulmonary embolus (PE), anastomotic leak, postoperative hemorrhage, or OSA. Data show that additional contributing factors may include the following:
• Failure to effectively treat
prophylactically for a DVT
• Delay or lack of diagnosis of leak or
hemorrhage
• Failure to diagnose OSA
postoperatively.

Implementing measures to consistently manage and evaluate patients for these potentially devastating complications, and measuring that compliance with those measures are key to improving clinical outcomes, as well as decreasing your liability exposure. Measuring clinical data is effective and easy, especially now with technology and web-based assessments, which also offer a more cost-effective way to do so. These new processes enable us to not only measure internal performance, but also benchmark against peers, taking the specialty as a whole to a higher level of quality and safety. The challenge is to get started and get ahead of the curve through innovation, measuring today what will affect reimbursement in the years to come.

3.    Engaging the bariatric patient. Improving bariatric patient engagement is one of the most important strategies in accomplishing the dual goal of safety and practice success. “Patient engagement” may also be called “family engagement,” “patient activation,” and “patient responsibility.” Bariatric surgeons are traditionally very good at this, but new tools and technology will help us go much further. Bariatric patients can make a significant difference in their own outcomes. They are a unique specialty population in that obesity is now well recognized as a chronic disease by the American Medical Association.[8] Whether through medical management for weight loss or surgical intervention, this population must be effectively engaged to improve their clinical weight loss outcomes by following the appropriate dietary regimen as well as eliminating health behaviors to prevent complications like stomal ulcers. However, to achieve this “buy in” to improve overall health, patients must be engaged.[9] Toward that goal, we must begin to make the bariatric patient a member of the care team. We must also document patients better and differently for the patients’ and the surgeons’ own benefits.

Using data to help patients and bariatric surgeons. Research and our own interactions show us that patients want to be engaged and that highly activated patients have better overall care experiences.[10] The ACA and the regulations surrounding Accountable Care Organizations (ACO) all require evidence of true patient engagement.[10,11] The good news is that patient engagement can reduce your professional liability exposure as well.

The importance of engagement is a new area of legal research and analysis. While still in its infancy, it is already showing promise as effective patient engagement may become a surgeon’s best legal defense.

Summary
Now is the time for bariatric surgeons to take safety to the next level and to explore the adoption of available technologies and tools. One cannot improve without first measuring. Compiling and analyzing patient data will not only help a practice to achieve reduced liability exposure, it will also serve as a foundation of measures to be used in future payer negotiations. Of equal importance, such data will be scrutinized by the public as consumerism becomes more fundamental in the face of quality and transparency. Today’s emphasis on outcomes, quality, and transparency does represent a fundamental shift in our profession, but it also gives us the opportunity to improve the lives of our patients while we enhance the overall quality and economics of our practices.

References
1.    Dallal RM, Pang J, Soriano I, et al. Bariatric related medical malpractice experience: survey results among ASMBS members. Surg Obes Relat Dis. 2014;10(1):121–124.
2.    Fullam F, Garman AN, Johnson TJ, Hedberg EC. The use of patient satisfaction surveys and alternative coding procedures to predict malpractice risk. Med Care. 2009;47(5):553–559.
3.    Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002. 2951–2957.
4.    Schletter K. Difficult patient—physician relationships and the risk of medical malpractice litigation. Virtual Mentor. 2009;11(3):242–246.
5.    Hablutzel J. Quality Improvement, reimbursement drive quest for patient satisfaction data. March 2014. http://www.mgma.com/practice-resources/articles/mgma-connexion/2014/the-business-of-care-delivery/quality-improvement-reimbursement-drive-quest-for-patient-satisfaction-data. Accessed August 11, 2014.
6.    Aguiar IC, Freitas WR Jr, Santos IR, et al. Obstructive sleep apnea and pulmonary function in patients with severe obesity before and after bariatric surgery: a randomized clinical trial. Multidiscip Respir Med. 2014;9(1):43.
7.    Finkel K, Searleman A, Tymkew H, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009;10(7):753–758.
8.    Frelick M. AMA declares obesity a disease. June 2013. http://www.medscape.com/viewarticle/806566. Accessed August 11, 2014.
9.    Weineland S, Arvidsson D, Kakoulidis R, Dahl J. Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT. Obes Res Clin Pract. 2012;6(1):e1–e90.
10.    Hibbard J, Greene J. What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013;32(2):207–214.
11.    Patient Protection and Affordable Care Act (PPACA), Pub.L. No. 111–148, § 3022, 124 Stat. 119 (2010); 42 C.F.R. § 425.10 et seq.
Appreciation to Surgi Protect and their cost control team for much of the research, and sharing their pro-active tools which were of grea000t assistance with the articles. http://www.mgis.com/products/medical-professional-liability. Accessed August 11, 2014.

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