by Candice Jensen, MD, FACS, FASMBS
Dr. Candice Jensen is surgeon and founder of the Bariatric Surgery Program at Yuma Regional Medical Center, Yuma, Arizona.
Bariatric Times. 2016;13(4):25–28.
Bariatric Center Spotlight: This column is dedicated to featuring accredited bariatric centers around the world, with a focus on their facilities, staff, statistics, processes, technology, and patient care.
Welcome to Yuma Regional Medical Center Bariatric Surgery Program
Yuma Regional Medical Center (YRMC) is a 406-bed, not-for-profit hospital serving the residents of Yuma and the surrounding communities of southwestern Arizona. In November 2008, according to a Quality Health Report based on data from the Centers of Disease Control and Prevention (CDC), Yuma, Arizona had the second highest obesity rate among US cities, with more than two-thirds of the population overweight or obese. Since then, the state and our center have been working to reverse these trends.
Our program came from humble beginnings. We started with a self-employed surgeon fresh out of fellowship, one hospital employed nurse, and a retired volunteer. The only available space at the hospital was a storage area behind the outpatient surgery department. Bariatric surgery did not exist at YRMC prior to 2009, so all specialty equipment had to be ordered before any cases could be done. Our surgeon was given a single day for block time to schedule cases.
Over time, the program expanded to include three additional employees, as well as a newly renovated bariatric center. All the details of building design and planning, down to the paint colors and inspirational center décor on the walls were approved by the founding surgeon and nurse. Our surgeon now has ample block time for bariatric cases—four days a week.
One of our earliest challenges was the lack of bariatric insurance benefits for hospital employees. We strongly felt, and still feel, that obesity is a disease, and that treatment of this disease should be covered by insurance companies. Further, we found it unethical to withhold lifesaving treatment from our own employees, while offering it to others in the community. While it took two years, we are very proud that YRMC changed their policy to cover bariatric surgery in 2011.
Meet the Staff
The YRMC Bariatric Surgery Department is a hybrid program, requiring cooperation and collaboration between the hospital administration, program employees, and private offices of the community surgeons and physicians. This relationship has taken years to build and expand, and is actively maintained with diligence from all parties, including our highly supportive past administrators (notably Cami Overton, Shawn Strandburg, and Jim Hall) We plan to continue this excellent relationship with our new CEO, Dr. Robert Trenchell.
Surgeon. Medical Director, Candice Jensen, MD, FACS, FASMBS, completed her general surgery residency at the University of Arizona. She then went on to complete a fellowship in metabolic and bariatric surgery at University of California, Los Angeles (UCLA). She currently serves on various hospital committees, and is the clinical site director for University of Arizona-Tucson third-year clinical clerkship in Yuma. She maintains a strong commitment to teaching patients, staff, and fellow providers about metabolic surgery. She maintains various national and local certifications and memberships, and is the founder of the YRMC Bariatric Surgery Program. Additionally, Dr. Jensen performs general surgical cases, including breast surgery, and takes emergency room call to maintain her skills and ability to provide a wide range of procedures to her patients.
Dr. Jensen is assisted in all bariatric cases by one of her partners in general surgery—Henri Carter, MD, and Margaret Kunes, MD, or George Deckey, MD. Drs. Carter, Kunes, and Deckey are American Board of Surgery certified.
Bariatric nurse coordinator. Rebecca Adame, RN, CCM, is the Bariatric Nurse Coordinator and a founding member of the program. She started her career in healthcare as a certified respiratory therapist technician. She became a licensed practical nurse (LPN), registered nurses (RN), and a certified case manager and bereavement counselor. This broad training and experience has allowed her to advocate for patients and help them gain access to the services they need within their own community, advance awareness of obesity, and shine light on the positive effects of weight loss in the Yuma community. Ms. Adame loves her job and her patients, and it shows. In 2014, she won the Yuma County Nurse of the Year award, selected from over 100 top performing nurses within our community. She is the face of our program. As Director of Clinical Operations, Ms. Adame is responsible for all aspects of the bariatric program. She is also responsible for maintaining the program’s website with current educational information, a widget for calculating body mass index (BMI), and the center’s patient photos and stories.
Patient liaison/certified hospital translator. Carmen Pulido is the patient liaison/certified hospital translator. She is a long-term employee who started at YRMC as a volunteer in 1998. Prior to joining the bariatric team in 2010, she worked in medical records, preadmission testing, and outpatient surgery. She is the engine of our program, driving patients toward a healthier future through surgery and beyond. We feel it is highly unique to have an in-program hospital certified Spanish language translator. She ensures we have a completely bilingual program and even teaches seminars in Spanish, so that every patient receives education in their preferred language. Additionally, Carmen is a certified massage therapist, and performs healing techniques such as lymphatic massage.
Registered dietitians. Registered dietitians Jacinta Santori and Jason Pawloski work together to cover multiple outpatient service areas, including cancer care, orthopedics, diabetes education, children’s rehabilitation services, and cardiac rehabilitation. They are based in the bariatric center, and are available to our bariatric patients during normal business hours. Additionally, they visit bariatric program inpatients, providing information and encouragement well before discharge. They also plan and facilitate our free monthly bariatric support groups, and produce “InControl,” our program’s monthly newsletter.
Metabolic and bariatric surgery clinical reviewer. Joana Lindberg, Metabolic and Bariatric Surgery Clinical Reviewer (MBSCR), joined the YRMC bariatric team in 2014. She works online from Flagstaff, Arizona to perform data entry and other duties for The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and National Surgical Quality Improvement Program (NSQIP). She attends bariatric meetings via telephone monthly and in person quarterly.
Volunteers. We have had several people kindly volunteer their time over the years. We’d like to extend a special acknowledgment to Penny E. who has come to every seminar since we started the program.
Office staff. Dr. Jensen shares office space and overhead costs with two other surgeons. Her office staff includes four full-time employees: Erin Aguilera, certified medical assistant; Gloria Aguilera, office coordinator; Amanda Gail, patient accounts and certified personal trainer; and Bobbi Roberts, certified coder.
These hardworking individuals are always willing to go the extra mile to fit bariatric patients into an oftentimes hectic schedule.
Community physicians and psychiatrists. We work closely with numerous private practice primary care providers, as well as various specialists in our community. We firmly believe patients should be able to choose their providers, and stay with someone they know and trust throughout their bariatric journey.
Postoperative ward. At least 80 percent of our bariatric patients are women, many with young children.We found that our patients were more comfortable recovering in a family friendly area, so in 2012-2013, we moved our bariatric surgery ward from the main postoperative floor to the Women and Children’s portion of the hospital. Jennifer Stanton, Director of Women and Children’s Services, was instrumental in our move, and arranged for all necessary physical ward improvements and educational requirements to be met well in advance of our move date. All rooms on our new bariatric ward are spacious and private with a flat screen TV, wi-fi, room service, wood flooring, and floor mounted toilets. Heart rate and continuous vital sign monitoring capability with information feeds to all nursing stations were installed on the new ward. Our team of dedicated nurses was quick to embrace the opportunity to care for these patients. One challenge we encountered in planning our move was the presence of bathtub/shower combinations on the Women and Children’s ward, which may not have met MBSAQIP certification for safety standards. During a multidisciplinary committee meeting, a simple solution was found: bariatric slide chairs that fit over the rim of the bathtub were purchased for minimal cost that allowed safe and simple independent entry/exit for patients without requiring any expensive remodeling. This is just one example of how our bariatric program came together to solve problems and achieve goals one step at a time through teamwork.
Operating rooms. YRMC has 16 total operating rooms; four in outpatient surgery, two in women’s surgery, and 10 in the main operating room. Additionally, there is a special procedure room in outpatient surgery, two c-section rooms in women’s surgical, and a hybrid catheterization laboratory/cardiac operating room. The four general surgical suites in the main operating room underwent extensive renovations in 2007, including placement of state-of-the-art laparoscopy equipment and expansion to double the square footage per suite. A dedicated endoscopy tower and glidescope intubation system are available in the room for every bariatric case. Each of our main operating room tables holds up to 1,500 pounds.
With patient and staff safety in mind at every step, we do not use gurneys at any point during a bariatric patient’s hospital stay. Patients transfer to the operating table independently. An air lift mattress device is placed on the operating table prior to every case, as well as a padded footboard and padded double thigh and arm straps. After surgery, patients are transferred directly onto their hospital bed using the air lift mattress. The patient is then encouraged to begin independent ambulation within four hours after surgery.
We utilize a dedicated operating room team, including an RN circulator, two surgical scrub technicians, an anesthesiologist, a surgeon and an assistant surgeon. All of our operating room supplies and equipment are checked for bariatric capability. In fact, all equipment hospital wide is marked with a weight sensitive color-coded label that is easily identified by staff.
Bariatric center. After completing the first 100 cases and after adopting electronic medical records (EMR), our small center proved inadequate to advance our program. We searched for a new home, and found it in the previous radiation oncology building. This large patient care area with leaded walls was perfect for our fluoroscopy and fully functional 1,000-pound-capacity operating table. In December 2012, after a complete renovation, we moved into the new space. We now have a dedicated suite for gastric band adjustments; patient care room; bariatric retail store for vitamins, protein supplements, and meal replacement items; private, bariatric-equipped restroom; private scale room; office space with private break room for bariatric staff members; a spacious lobby with a 66-inch flat screen TV; and multiple storage areas. The bariatric center is connected to the hospital-wide EMR system, with multiple mobile and desktop stations for staff members and providers to enhance productivity. We also use a patient tracking system (Exemplo Medical, Oldsmar, Florida) and enter data through the MBSAQIP system. No patient visit is complete without a weight/BMI check, using our body analysis system (Seca, Hamburg, Germany). In addition to fluoroscopy, we have a standard abdominal ultrasound machine for use within our bariatric center. Within the same building, we have access to a large conference room, wound care center with hyperbaric capabilities, cardiac rehab gym with exercise physiologist, lab, and outpatient radiology department.
Programmatic Focus on Quality Improvement
At YRMC, we are passionate about improving all aspects of our program, and feel this is best demonstrated through quality improvement projects. We have a well documented and robust enhanced patient recovery program, including protocols for reducing postoperative nausea and vomiting and multimodal analgesia/narcotic reduction. Our main goal is prevention of problems, starting with patient education in the preoperative period.
We have made a commitment to minimizing emergency room visits using a team approach and an open-door policy in both the bariatric center and the private surgery office. Patients are educated before surgery on warning signs and when to seek medical attention. During business hours, we see patients on an urgent basis at either location. We utilize outpatient services for IV hydration, lab work, imaging, and, when necessary, facilitate direct admission to the hospital, always to the operating surgeon’s service. At the time of our accreditation site review, we had zero emergency room to hospital admissions in over one year. We are also the proud recipients of the 2014 Healthgrades award for achieving 95th percentile patient satisfaction.
Achieving accreditation. YRMC is the only US hospital for over 100 miles, and the only US bariatric center for over 200 miles. Our general surgeons have been performing rescue operations for patients who have had weight loss surgery elsewhere but experienced a complication while in Yuma for many years. When starting the program in 2009, Dr. Jensen and her staff felt it was vital to pursue accreditation. Our program was created to meet multiple accreditation requirements but, as a single surgeon with multiple insurance barriers, our center did not meet the requirements for volume under the old Centers of Excellence program . When the American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgeons (ACS) joined to form the new Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), we submitted for accreditation.
We were thrilled to receive comprehensive center accreditation on August 15, 2015. In the summary report we received of our site visit, the surgeon reviewer remarked, “This center comes as close to ideal as any that I have encountered.”
Over a year of preparation went into the site visit day. We hired an expert consultant (Lynne Thompson Consulting, St. Petersburg, Florida) to help create clinical pathways and prepare our hospital for a successful survey. Our hospital was already participating in NSQIP, which made data entry requirements easier to achieve.
Our nurse coordinator knew that staff awareness of the site visit was key to its success. She placed “BlueBari Bathroom Blast” information sheets on the door of every staff bathroom stall that included the date of our site visit and a few key points about bariatrics. “BlueBari” binders with program and equipment information were available in print form on every unit and electronic version available from any computer hospital wide. All members of the bariatric team, Biomedical Engineering, and Purchasing departments went from room to room to ensure hospital-wide bariatric sensitive stickering of all equipment. We also hosted several mock site visits, and held a formal run through on May 14, 2015, reminding each department of when they would be visited the next day.
On the day of the visit, we showed a united front, starting with a meeting in our most upscale boardroom with all of the hospital’s executive leadership present. We created a welcome packet and slides to greet our site reviewer. All supporting documents, which were triple checked for accuracy, were organized into binders and available for review. The director of each department was alerted 10 minutes before their visit via our in-hospital communication system.
At YRMC bariatric surgery program, we are action oriented, and we demonstrated this during our site visit. We worked closely with the operating room leadership and staff to set up and seal off an operating room for a full hour to show the surgeon surveyor that we had sufficient equipment to safely perform bariatric surgery.
Staff Education and Training
Inservice education. Inservices are held semi-annually to address sensitivity, transfers, patient safety, hiring processes, and updates for core ward staff. We also have inservices annually for preoperative, operative, and post-anesthesia care unit (PACU). Additionally, online education utilizing the Healthstream system is required annually hospital wide.
Medical staff education. Dr. Jensen and her staff regularly attend medical conferences to keep up to date. They share new research, trends, and ideas with the multidisciplinary care team.
Our timeline of patient processing is as follows:
1. Seminar-surgeon lead. The patient receives an information folder. We believe that the patient should choose the surgical procedure they feel is right for them after we provide education.
2. Patient receives information binder. Available in English or Spanish.
3. Monthly support groups. The patient is encouraged to attend monthly support group, which are led by our RDs.
4. Coordination of insurance benefits, medical work up, and clearances.
7. Recovery. While a patient is in the hospital, we ensure they receive our attention through staggered surgeon rounds, coordinator rounds, and RD visits.
8. Discharge. All patients receive an amenity bag with an emergency room alert card, which includes the name, date, and picture of their specific procedure as well as contact numbers for the bariatric nurse and surgeon.
Postoperative care and follow up. All postoperative care is surgeon directed. Process for follow up includes the following: letter and email recall system, yearly labs, phone calls for missed appointments, standardized follow-up schedule.
In order to achieve 100-percent approval for policies that do not have a bariatric benefit exclusion, we consider the following:
• Know each policy. This can be challenging due to the Affordable Care Act and marketplace plans.
• Prepare for insurance issues prior to consultation.
• Strongly encourage use of insurance, but have self-pay option available.
• Submit only clean, complete claims.
• Provide appropriate paperwork.
• Use combination medical necessity and referral form.
• Provide six-month medical diet forms to the patient’s primary care providers.
• Use of peer-to-peer review. Surgeon contacts the insurance company’s medical director via phone when a patient’s surgery is denied due to lack of “medical necessity.”
• Use of Obesity Action Coalition. The OAC has provided support in cases of insurance denials of surgery. For instance, we reached out to the OAC about a patient case and they sent a letter to the insurance company urging procedure coverage. The decision was overturned and the patient’s surgery was covered.
A Unique Facility
At YRMC Bariatric Surgery Program, we understand the emotional and physical struggles of obesity. Our caring team of experts is dedicated to helping the people of Yuma and southwestern Arizona permanently lose weight. Here, patients can count on excellent care from the first appointment to post-surgery and beyond. We are 100 percent devoted to delivering the highest quality patient care, and have been recently been recognized as an accredited Comprehensive Bariatric Center by the MBSAQIP, allowing us to serve even more of our local and regional population and helping to treat the debilitating disease of obesity.
For more information regarding our program, please visit www.yumaregional.org/bariatric-surgery.
1. Banner V. 10 Fattest Cities in America. November 20, 2008 . https://www.qualityhealth.com/dieting-articles/10-fattest-cities-america. Accessed March 7, 2016.
FUNDING: No funding was provided.
DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.