New Life Center for Bariatric Surgery

| December 15, 2011 | 0 Comments

Knoxville, Tennessee

by Jama Stinnett, LPN, CPH, Office Manager, New Life Center for Bariatric Surgery, Knoxville, Tennessee.

Funding: There was no funding for the preparation of this article.

Disclosures: Dr. Boyce is an educator for Ethicon Endosurgery. Dr. Williams and Ms. Stinnett report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2011;8(12):22–26

Welcome to the New Life Center for Bariatric Surgery
The New Life Center for Bariatric Surgery (NLCBS) associates with Parkwest Hospital in Knoxville, Tennessee, a 300-bed hospital. Together they were first recognized as a Bariatric Surgery Center of Excellence (BS COE) in 2005.

Our staff
Registered nurses. Each physician has a registered nurse (RN) that works directly with him or her to coordinate the care of the community of patients. We support our nurses’ efforts to become Certified Bariatric Nurses and have one of the first certified bariatric nurses in the country. Our second RN is currently studying for the bariatric nursing certification exam. These nurses participate in the education, evaluation, and follow up of patients. They present information at introductory seminars, including a description of how the patient will interact with the nurse, present a 90-minute educational program attended by every presurgical patient, and see patients at both the 2 Week and 1 Month postoperative visits to evaluate their condition and progress. They take patient phone calls 24 hours a day, seven day a week so that patients get consistent advice when they need it most. Each nurse takes her surgeon’s patients’ calls during the day then after hours, rotates taking calls on a cell phone number that is given to each patient just before surgery.

Registered dietitians. Our dietitians, one Masters-prepared and one with special certification in adult weight management, play a critical role in our office-based bariatric program. They provide an overview of the diet plans at our introductory informational seminars and a 90-minute educational program on postoperative diet phases that each presurgical patient attends. They take the lead in review of research and education on current advances in vitamin and mineral management of the bariatric patient and see patients postoperatively for diet and nutritional status management. Management of postoperative patients is accomplished through a triad of consulting with the surgeon, the dietitian’s professional expertise, and carefully crafted algorithms that provide consistent, efficient, and effective care.

Life coach. Patients are provided with a free informational class with a life coach. After this introduction, the patients may choose to continue with additional classes. These classes are arranged as an adjunct to standard of care if the patient chooses to attend them.

Exercise physiologist. We employ two exercise physiologists. They provide our patients with the additional support, accountability, and information needed to successfully incorporate exercise into their “new life.” The exercise physiologist begins working with patients at the 3 Months Postoperative visit. They also provides an overview of the importance of exercise in our introductory seminars.

Patient advocate. Our patient advocate desk is staffed by the exercise physiologists. While providing cross coverage for the exercise position, they coordinate marketing projects and explore ways to advance our image in the community. They talk with patients who are inquiring about our program, visit referring physicians, and manage social media and websites. Visits to referring physicians are designed to provide the referring physician with information on current advances in postoperative bariatric care and the ease of referring patients to our center.

Part-time nurse practitioner. Our nurse practitioner sees patients for a final comprehensive review of their physical status and readiness for surgery and coordinates postoperative care with patients’ primary care physicians and specialists.

Care coordinators. Our experienced scheduling coordinators each work in concert with a physician and their patients to provide consistent advice, extensive instruction on the preoperative steps a patient will experience, financial counseling, pre-collection of payments, and coordination of care with other providers as needed.

Predetermination coordinator. The predetermination coordinator assists patients in collecting all the needed documentation for the insurance predetermination approval letter that will be submitted to their insurance company. She also provides the team with information on the most current insurance approval criteria, and interacts with the third-party payers to obtain the needed approvals for surgery.

Receptionist. The receptionist manages the patient flow, obtains all needed data from the patient on arrival to each visit, collects copays and overdue account balances, updates patient information, and maintains a warm and friendly reception area for patients during their visits. All clerical staff members participate in the maintenance and sales of our retail line of vitamins and protein supplements.

Office manger. The office manager ensures that staff and physicians have the resources they need to perform their jobs. She oversees the functions of the site, including marketing, customer service, and review of the appropriateness of reimbursements. Leadership of the team in pursuits of quality improvement, service excellence, special projects, and recognition by center of excellence certifying bodies are also within the office manager’s responsibilities. She meets with each pre-operative bariatric patient to insure their readiness and confidence in the process.

Our facility

We are fortunate to enjoy 4,080 square feet of space specifically designed for our patients and processes. Our facility consists of a 25-seat reception area with all bariatric seating and a Tanita scale (Tanita Corporation, Tokyo, Japan) that patients may use without appointment; a conference room with educational audio visual equipment that seats 20 bariatric patients at tables; two private physician offices, private administration office, predetermination coordinator’s office; a procedure room outfitted with fluoroscopic equipment for band fills and upper gastrointestinal (UGI) studies; four exam rooms; two consultation rooms used for dietitian and exercise physiology visits; cubicles for use by the patient advocate, nurses, and dietitian’s when not in consultation with a patient; a laboratory outfitted for an outsourced phlebotomist as well as in-house testing for basal metabolic rates and Helicobacter pylori (H. pylori) testing; and display and storage areas for our private-label vitamins and dietary supplements.

Patient Demographics
We see about 750 bariatric consultations in our office each year, resulting in about 450 bariatric surgery cases. The largest percentages of our cases are Roux-en-Y gastric bypass (RYGB) followed closely by biliopancreatic diversion with duodenal switch (BPD/DS), then sleeve gastrectomy (SG) and adjustable gastric banding (AGB). We also perform a small number of distal gastric bypasses. About 15 percent of our cases are self pay and we include BLIS™ bariatric complication insurance (BLIS, Inc., Lake Oswego, Oregon) in our self-pay package.

An American Society of Metabolic and Bariatric Surgery Center of Excellence
We do not find that many patients have sought out our practice for our ASMBS certification unless their insurance carrier requires it as with Medicare. The process of becoming a COE was in our plan when we started our program and the program was built around the criteria. The process of obtaining this designation was a natural result of the maturation of our program. We first obtained designation as a Center of Excellence for ASMBS in August 2005.

Patient Adherence and Long-term Follow Up
We are always seeking to increase patient adherence with the program that will bring them the most success. We find that having an office-based program gives us the freedom to imbed the services that help patients buy into the program and achieve the best results.

Access to an in-house exercise physiologist, frequent visits, support through availability of the multidisciplinary team members, and our in-house line of vitamins are all important components of making adherence more achievable.

Our recent research shows that patients will search for new coping mechanisms to replace the use of comfort food. Helping patients to focus on what new behaviors they will add to their lifestyle is an important way to address adherence. By addressing this expected outcome and encouraging exercise through education and availability of support staff, we give patients the knowledge and collaborative assistance they need to seek positive behaviors.

Our private-label line of vitamins provides an easy and inexpensive way for patients to meet the ASMBS-recommended vitamin supplement guidelines. Eliminating guess work about what to take and having the supplements available both in our office and online gives the patients ease of access to what they need. We find that about 50 percent of our patients stay compliant with our in-house vitamins.

Rare but serious complications can occur due to dietary nonadherence. We have seen isolated cases of actual physical damage to fresh surgical sites from overeating or eating the wrong foods. Unfortunately, we occasionally see patients from other practices or patients who have traveled outside of the United States for their surgeries (medical tourism) and received no follow up or education. Missing both of these important pieces of follow up is a recipe for disaster, and we fear that more patients will have unfortunate outcomes as medical tourism increases and are grateful that the ASMBS is trying to address these concerns.

Pre-Operative Process

Pre-screening and preparation. Patients must attend an initial informational seminar. This seminar includes information on the disease process, surgical alternatives, risks of surgery, patient’s responsibilities, surgical pathway, and financial aspects of the program. The surgeons of NLCBS and the members of the bariatric team, including the NLCBS Bariatric Patient Coordinator, Bariatric Office Coordinator, Registered Dietitian, Exercise Physiologist, and Office Manager make presentations.
Patients need to obtain a written recommendation from their primary care physician (PCP), and complete forms providing complete medical history and detailed diet history.

Initial consultation. In the initial consultation, the surgeon evaluates surgical appropriateness and schedules radiological exams and other testing if needed. Patients receive oral and written instructions for a preoperative diet. The staff provides instructions and assists patients in scheduling appointments to obtain clearances from all other needed specialty services, such as psychological screening by a psychologist or psychiatrist, which may include pulmonologist, cardiology, and any other needed services identified by the surgeons’ review of the patients’ exam, history, and primary care physician’s  recommendations.

Financial counseling and payment arrangement. NLCBS works vigorously to assist medically appropriate patients with financial arrangements to procure surgical weight loss. Assistance is provided in establishing documentation of medical necessity for patients’ third-party payers’ guidelines where appropriate. All patients are responsible for any noncovered benefits identified. These costs may include education, diet instruction, various related educational classes, and physical education instruction and opportunities.

Patients without medical coverage or whose coverage cannot be confirmed are required to pay for their procedure before services are rendered. NLCBS will assist the patients in applying for credit programs currently offered through our office. NLCBS offers the following as credit programs: 1) (with approved credit) allows VISA credit line to pay for medical expenses, 2) automatic bank draft program through NLCBS, 3) Chase financing program, and 4) other bank loans and financial programs as they become available.

Other considerations. Patients requiring additional medical weight loss programs before becoming candidates for weight loss surgery are referred to the medically supervised weight loss program of their choice or as required by their insurance company. Progress in the program is monitored via interaction by the Predetermination Coordinator in our office. At such time, as all needed pre-screening tests and consultations are successfully completed and financial arrangements are complete, the patient is scheduled for surgery. Once scheduled, the patient returns for surgical preparation education class. These classes are conducted by NLCBS staff including, registered dietitians and registered nurses. This class further educates the patient on the peri-operative experience; life-long commitment to diet, exercise, and medical follow up; and emotional challenges involved in pursuing bariatric surgery. The patient demonstrates comprehension of the material by completing a test.

Patients with a body mass index (BMI) of 50kg/m2 or more begin a protein-sparing, very low-calorie diet four weeks before surgery and are scheduled for a final preoperative appointment. Patients with a BMI below 50kg/m2 begin this diet two weeks before surgery.

Patient’s baseline information is then placed in the ASMBS Bariatric Outcomes Longitudinal Database (BOLD).

Final preoperative appointment. At the patient’s final preoperative appointment and completion of at least one visit to a support group, he or she is presented the opportunity to enter into the lifetime commitment statement and given written informed consent for bariatric surgery. At this time, the patient undergoes laboratory exams based on the particular surgical procedure at a minimum to include the following: basic metabolic panel, complete blood count (CBC), B1, B12, H. pylori, basal metabolic rate, vitamin D, and iron.

On the same day as their final pre-operative visit in the office, the patient will attend hospital pre-admission. This hospital appointment includes anesthesia consultation, preparation instructions, medication review and any review of any needed administrative information for the hospital.

After these steps are complete, the patient can then proceed with surgery

Postoperative Process
Patients undergoing bariatric surgery are prescribed strict postoperative follow up.

Diet. Patients will be given specifics of what is to be eaten during each postoperative period, will have a weekly opportunity to revisit the diet education class with the bariatric coordinators, and will have diet counseling at each postoperative visit with the registered dietitian.

Exercise. Patients will be evaluated beginning at three months by the exercise physiologist and educated in simple routine exercises that are to be followed daily. They will have increased access to the dietitians and exercise physiologists for the first 12 months after surgery, including the ability to use secure e-mail for simple questions.

Services offered by NLCBS in postoperative period. Our staff responds rapidly to patient calls received on the 24-hour bariatric call line staffed by our nurses.

They utilize surgeon-approved algorithms for routine calls and surgeon backup for non-routine calls.

We offer patients support of emotional status through use of support groups. All patients are encouraged to participate in local support groups. A patient may attend a support group moderated by a healthcare professional provided on a monthly basis at Parkwest Medical Center.

Patients will continue with visits to psychologist and/or psychiatrist as needed. Psychology appointments are available through a psychologist on the NLCBS campus or may be scheduled with a provider of the patients’ choice.

We schedule routine office follow up appointments at the following phases postoperatively:
•    2 weeks postoperative. The patient visits with an RN
•    4 weeks postoperative. The patient visits with Nurse and Dietitian.
•    3 and 6 months postoperative. The patient visits with the Dietitian and Exercise Physiologist.
•    9 months postoperative. The patient visits with a Life Coach for introduction to the Bariatric Life Strategies class.
•    12 months postoperative. The patient visits with the Dietitian and Exercise Physiologist. He or she is referred back to the primary care physician if routine follow up is desired.

Patients will be followed annually (at a minimum) after the first year. Face-to-face visits after the first 12 months are not required unless the patient is not receiving routine follow-up care, including appropriate vitamin level assessment by their PCP.

NLCBS will continue to monitor the patient’s progress through his or her PCP and collect data on outcome for five years.
Additional visits are scheduled with any or all NLCBS team members as deemed necessary by the team or as requested by the patient or PCP.

Immediate postoperative care. In the peri-operative education class, patients are educated on the following items, which are reinforced by hospital staff:
•    Prescribed walking or other exercises beginning two hours after arriving to the surgery floor, unless contraindicated.
•    Consultation with therapy department for exercise as needed.
•    Immediate postoperative exercise
•    Prescribed ambulation (8am through 8pm, every hour)
•    Light stretching
•    Ankle rotations
•    Toe pumps
•    Toe circles
•    Nursing interaction
•    Pulmonary demands
•    Incentive spirometer
•    Coughing
•    Diaphragmatic breathing
•    Recovery phase
•    Patient participation in monitoring oral intake and activity.
•    Morning rounds by patient’s surgeon
•    Afternoon rounds by hospital-based bariatric coordinator

Quality Management
Patients are monitored on a presurgical screening list during the pre-operative process to evaluate and facilitate progress in completing all presurgical requirements.

Postoperative visits and continuity of care are monitored by the NLCBS No-Show, Cancellation and Follow-Up Procedure, which provides steps for reconnecting with patients that do not keep regularly scheduled appointments.

Outcome indicators are collected to facilitate outcome management as well as continuous process improvement plans. We report data to the Bariatric Outcomes Longitudinal Database (BOLD) and adminster education comprehension testing to assess improvement needs in educational programs and specific reeducation needs in each patient. Outcome management is a function of the review of Bariatric Outcomes Data at the Hospital Based Bariatric Oversight Committee meeting.

Technologies, Equipment, Devices, and Products
Large-dose vitamin D injections have recently been shown effective in treating vitamin D deficiencies.[1] In May 2011, we began administering vitamin D 600,000 units intramuscularly (IM) to patients with vitamin D below 15ng/mL or who fail to normalize with 50,000IU  three times weekly. Early results on this treatment are promising and decrease issues with adherence since patients do not have to take a daily dose. The dosage is not commercially available and must be obtained from a compounding pharmacy.

Dr. Stephen G. Boyce has just completed training to perform laparoscopic greater curvature plication (LGCP) for weight loss. This new procedure has promising early results of weight loss in the same range as sleeve gastrectomy in a reversible, less complex surgery.[2 ]

Procedure Scheduling and Inventory Management
Our scheduling is done by our care coordinators. These experienced schedulers are exclusively responsible for interacting with patients regarding their progress through our program, scheduling of all appointments inside and outside our office, and scheduling surgery. Our scheduling software (Vitera Intergy EHR Software [formerly Sage Intergy], Vitera Healthcare Solutions, Tampa, Florida) is not complex or bariatric specific but has user-defined features that let us designate types of appointments and create templates to guide what items can be scheduled at what times.

Day-to-day inventory of our medical supplies and small equipment are requisitioned electronically by our vendors on their websites. They contain a feature that allows the requests to be composed by a staff member and then viewed by the manager for approval before actual submission.

Evaluations of new equipment or larger purchases are screened by the manager who then involves the surgeons and other staff who have expertise and will have direct use of the item.

Managing Patients’ Care
Patients are assessed by the surgeon at the consultation visit to determine appropriateness for surgery. Consultations for needed clearances are ordered at that time. The physicians review the clearances as they come in and the pre-determination coordinator insures that all ordered screening tests, approvals, and consultations are received before passing the patient’s file on to the office manager for final approval. The patient is then forwarded to the care coordinator to contact the patient and surgery is scheduled. Our software has a tasking system that tracks the movement through the office. As patients move through the process, any staff member is able to access the progress, which allows any staff member to handle a call or question about that patient. Staff members are encouraged to bring up cases in the weekly patient review meeting for additional discussion or concerns.

The Role of Managed Care Payers
A bariatric patient’s access may be defined by his or her managed care product. Patients whose insurance plan does not provide coverage for the care of obesity are often unable to access care. About 15 percent of our patients seek care outside of a third-party payer and self pay. Payers also direct care to specific providers based on center of excellence designations.

The utilization management criteria set up by each managed care has become a part of our screening process and is manageable, but may represent significant increase in the cost of providing care as well as delays in patients reaching the care they need. Ultimately, it is rare for a case not to be approved since there are so many viable candidates and inappropriate candidates are screened out by the provider based on medical necessity. The predetermination coordinator maintains a spreadsheet of the most common carriers and their requirements in each exam room so that the surgeon can manage the patient’s expectations and order the needed screening tests.

Cost and Efficiency
Staff involvement in the review of processes yields a culture of ongoing quality improvement. If a culture that values staff input is in place, staff will continually go the extra mile to improve the practice. An example of this is our decrease of copier use by 20 percent over one year. This savings came as a result of staff reviewing their educational pieces and processes and finding ways to decrease paper through improvement in the educational materials. After moving some to digital format and front to back copying, the materials were improved and a significant savings was realized. This type of engagement of staff facilitates tangible quality improvements.

Embracing electronic health records (EHR) has helped us to create templates for use during visits that not only meet documentation requirements but also remind providers of needed services and keep the visit on track to achieve the purpose for which the visit was scheduled.

Availability of C-arm equipment in our office has decreased the time and cost of band adjustment visits for both the patient and provider.

We have found that empowering employees to handle repetitive issues through algorithms allows for quicker resolution and consistent advice to patients. Thorough review of cases and screening prior to scheduling decreases last minute cancellations for additional screening or unexpected issues.

We also saw improved efficiency when we changed the staffing model to decrease use of our nurse practitioner only when that skill level was required.

Our physicians and staff use digital tablets, such as iPads, to allow providers to show video and record data on the fly while in the exam room.

Patient/caregiver safety and education
Staff safety is addressed according to Occupational Safety and Health Administration (OSHA) regulations, including use of universal precautions and readily available personal protective equipment. We do not see patients that require lifting in the office unless they are transported by emergency medical technicians (EMTs) who stay with them.

Our electric multi-position exam table that lowers all the way to the floor is an advantage when caring for patients that have limited mobility.

We have hand rails around our scale to assist patients as they step up to be weighed, and locks on the doors from the reception area to the clinical area help us control patient access. This allows us to more easily protect patient’s privacy and the security of our records and office.

Patient/caregiver safety and education
New employees have two days of corporate managed training on: human resources topics and corporate policy, computer application training, healthcare compliance, and benefit plans.

Office and job-specific orientation include partnering with a preceptor who signs off on the employee’s task list as tasks are acquired. The manager follows up with observation of acquired skills and signs off on the task list until all essential tasks are acquired.

A questionnaire administered after 90-days of employment is used to assess employee satisfaction and needs. Fostering in the first few months of work experience is critical to an employee’s success. Employees need to clearly understand what the practice expects of them and have tools to facilitate accountability. These small details may sway the balance between success and defeat for new employees. Investing in continuing education for staff is an important mechanism for improving the care they are able to give as well as engaging the employee.

We have an open-door management policy for informal updates of status and needs of all employees and conduct weekly staff meetings that address ongoing education in technical skills, newly published research, procedure review, and customer service. These meetings also involve opportunities for the staff to submit and discuss their creative ideas on how the patients’ needs are met. Leadership must come from the top down if you are to achieve real customer service stars in your practice.

Emerging Trends
There has been some attention of late to the gaps in research for the fields of bariatrics and we expect to see focus on technology to improve quality of life through life coaching, increased understanding of the role and interventions with micronutrients, as well as more nonsurgical revisional and primary interventions such as the LGCP. We are recruiting patients for this investigational procedure. Early results of LGCP offer promise in reducing cost and complications while providing outcomes similar to those with other restrictive procedures. Further, the procedure does this without use of foreign body or any irreversible anatomy changes.[2]

There are definite trends and acceptance of interventions for treatment of diabetes in an expanding population of patients with lower BMIs. This trend is being mainstreamed by recognition from organizations like the American Diabetes Society, National Institutes of Health (NIH), and the United States Food and Drug Administration (FDA).

We are absolutely always reviewing new technology, procedures, and medications that will advance the treatment of obesity and are very open to educating ourselves to provide these choices to our patients.

A Unique Facility
The commitment and involvement of our surgeons is what differentiates our facility. The culture and standards of the practice and commitment to clinical outcomes and customer service. In the words of our medical director, Dr. Stephen G. Boyce, “We are willing to commit, if you are.” That is the credo that is conveyed to our staff not just by words but by actions. Our staff models themselves according to what they see in their leaders. Our surgeons invest their time and resources in making this practice one that always helps each patient reach their best recovery potential. This pre-eminent program is a result of comprehensive involvement and an unyielding leadership. The following is just a few of the undertakings that culminate in excellence in outcomes and service.
•    Insuring consistent care through accountability systems and algorithms for treatments.
•    Leadership in weekly staff meetings that sets the culture, educates staff, and encourages their involvement in every aspect of the practice.
•    Personally educating hospital staff from the floor nurses to the operating room staff.
•    Availability to the hospital-based bariatric coordinator to discuss ongoing care according to his or her needs.
•    Leading a multidisciplinary committee that oversees the hospital bariatric program.
•    Continually making time for continued education on all aspects of research that affect our patients.
•    Participating in research projects on issues of importance to patients.
•    Allotting resources to developing and delivering education for PCPs working with bariatric patients.
•    Community involvement in events, such as patient seminars with the American Diabetes Association (ADA) and Walk from Obesity.
•    Leadership of quarterly review of the staff involved in hospital care covering every issue from outcomes to surgical instrumentation.

To learn more about NLCBS, please visit us at

Patient photos.

Meet the Staff.

NLCBS surgeons.

Other photos.

An Interesting Case.

Fluoroscopy equipment for adjustable gastric band evaluation clinic.

1.    Einarsdóttir K, Preen DB, Clay TD, et al. Effect of a single ‘megadose’ intramuscular vitamin D (600,000 IU) injection on vitamin D concentrations and bone mineral density following biliopancreatic diversion surgery. Obes Surg. 2010;20(6):732–737. Epub 2009 Dec 1.
2.    Cottam D. Gastric Imbrication: The Future or Fantasy? Expert Panel Meets To Discuss Major Questions About New Procedure for Weight Loss. General Surgery News. 2011;38:7.


Category: Bariatric Center Spotlight, Past Articles

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