Managing Outcomes, Meeting Expectations

by Philip R. Schauer, MD

Philip R. Schauer, MD, is Chief of Minimally Invasive General Surgery and Director of the Cleveland Clinic Bariatric and Metabolic Institute. He is also Professor of Surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He is Past President of the American Society for Metabolic and Bariatric Surgery.

Bariatric Times. 2016;13(2):20–21.

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Over the past decade, bariatric surgery complication rates have declined considerably,1 driven in part by the American Society for Metabolic and Bariatric Surgery’s (ASMBS) intense focus on clinical excellence, as well as the introduction and wide adoption of laparoscopic surgical techniques. Continued surgical approach innovation and a shift in payor requirements for performance have also helped.

In addition, patient education has improved, eligibility requirements have evolved, and patients are demonstrating greater commitment to life-long lifestyle changes. Finally, I believe the focus of medical professional liability insurers in supporting bariatric surgeons and their programs to mitigate liability risk has also had a positive impact on outcomes.

Heightened expectations
Amid these improvements, patient expectations are high. Those considering bariatric surgery have greater access to publicly available information—including surgeon and hospital satisfaction scores—than ever before. Such data generally lead patients to seek out more experienced and high-scoring surgeons and bariatric programs, which tends to reinforce or boost high expectations for favorable results, whether that means low complication rates, superior weight-loss results or, most commonly, both.
Bariatric surgery programs can align consumer expectations with clinical reality through solid patient education that threads throughout the process—from patient education through surgery to post-surgery processes.

An important tool for surgeons is the informed consent form. The informed consent process for bariatric surgery is perhaps more comprehensive than for any other surgery—painstakingly listing potential complications a patient could incur. The form can be five-pages long, as it endeavors to clearly spell out the serious nature and potential risks of the surgery.

Payor expectations have changed, too, in part due to increased awareness driven by peer-reviewed, published literature. Of course, payors expect the same high-quality results as do patients. In addition, they also focus on surgery costs. Payors diligently evaluate things like length of stay, readmissions and comorbidity reduction as part of their quest for quality care at lower costs.

Surgeon response
To deliver what patients and payors seek, surgeons must strive to provide optimal bariatric surgery safety and outcomes. Adequate training and skills maintenance are key. Actively participating in a program, such as the ASMBS and American College of Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), can help surgeons boost quality and outcomes.

Ultimate responsibility lies with the surgeons, who must continually work to improve their operations and team-member proficiency. Taking part in structured quality meetings and morbidity and mortality meetings can help bariatric surgeons monitor errors and complications. It can also help them drive bariatric surgery improvements and reduce complications and mortalities.

High-performing bariatric surgery programs have one thing in common: they’re passionate about taking a multidisciplinary approach to bariatric surgery patient care. They require coordination and collaboration among various departments and staff, and they maintain a formalized program with clinical protocols, processes, and procedures that have the buy-in from the relevant disciplines.

Minimizing risk
Risk mitigation begins well before a surgical procedure occurs. Strategies around patient selection, managing patient expectations, the informed consent process, and procedure-specific informed consent are important elements. So too is developing a trusting and open surgeon-patient relationship. Upfront work in this regard can boost the likelihood that, if an adverse event occurs, patients won’t seek out a plaintiff attorney.

The good news is there’s a way to assess surgeon-patient relationships. I’ve been involved in evaluating this question and creating a bariatric-surgery-specific patient survey that looks at experience of care. This survey helps bariatric surgeons gather information, objectively and anonymously, about their patients’ experiences with the program. The tool provides the surgeon real, useful, and timely information. If we as bariatric surgeons don’t know what our patients think about us and our program, then we can’t address concerns before adverse outcomes occur.

Relationship-building goes beyond patients. Working with and developing trust among spouses or other family members is also important. If a significant adverse clinical outcome occurs, the spouse or family member could be surprised and assume negligent care, even though the surgeon explained the risks to the patient during the pre-operative period. Involving families in pre-surgical surgery risk discussions can be very helpful from a liability perspective.

If a clinical adverse outcome does occur during surgery, identification of the issue and an attempt to address in a timely manner are vital. An important element of this is documenting the identification as well as the surgeon’s thought process in addressing the issue.

Too often we see lawsuits involving known complications, such as a leak at the anastomosis, in which patients take legal action if the surgeon identifies the leak in a timely manner, but then fails to adequately document steps and actions taken to evaluate and address it. This is fertile ground for plaintiff attorneys to say that no evaluation took place and no adequate attempts were made to address the issue.

All of the pre-surgical work the surgeon and the program did comes into play if something goes wrong. Expectation management, the informed consent process, and trusting physician-patient—and physician-family—relationships all contribute to open and honest post-surgical communication.

These conversations help everyone understand what happened and why it happened. They are bolstered by an internal, confidential investigation with your risk management team and/or your medical professional liability insurer. Armed with information, it’s easier to address liability risk early, before a patient ever seeks an attorney, and to resolve the issue in a fair and cost-effective fashion, without the need for litigation. This is a win-win for everyone—the patient, the family and the surgeon.

Professional support
About 10 years ago, risk management support from medical professional liability insurers was relatively rare. Today, it’s imperative. Too often, though, insurers are trying to be all things to all specialties. As you know, bariatric surgery is a unique specialty with similarly unique liability risks.

I believe it’s important for us in the bariatric surgery arena to support and engage with insurers that specifically focus on and understand our specialty. Today, I work with a program called Surgi-Protect™ (The MGIS Companies, Salt Lake City, Utah), which provides bariatric-surgery-specific risk management to its bariatric surgeon insureds. The program includes adverse event management support for when a less-than-desirable event occurs.

This support, delivered by professionals with experience and specific training in bariatric surgery, includes bariatric-surgery-specific risk management tools, checklists, and protocols, as well as a patient experience survey tool and support. Bariatric surgeons and programs without such support are, in my opinion, at a disadvantage.

In today’s ever-changing healthcare environment, it’s beneficial for you to work with an insurer that understands what’s important to bariatric surgeons, and that offers risk management counsel and tools that support that. This is true for all bariatric surgeons, but especially so for those who aren’t part of a large physician practice group or a hospital system with their own relevant resources.

Future success
Bariatric surgeons can meet the heightened expectations of patients, their families, and payors. Doing so requires clear commitment to solid communication, appropriate pre-surgery protocols, ongoing training and practice monitoring, and a clear industry-specific risk management focus. Making use of all available resources, including those offered by your medical professional liability insurer, can help drive positive results—and fewer negative ones—going forward.

References
1.    Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg. 2014;260(3):504–508; discussion 508–509.

Funding: No funding was provided.

Financial disclosures: Dr. Schauer serves on the Board of Directors for SE Healthcare Quality Consulting, Charleston, South Carolina.

Tags: bariatric surgery

Category: Brief Report, Past Articles