Bariatric Times

SEP 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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15 Review and Case Study Bariatric Times • September 2017 P art of the preplanning effort must include provision for communication. Although sometimes difficult to arrange, a face-to-face interprofessional team c onference planned within 24 hours of admission might prevent costly economic and clinical consequences later. Consider including the patient and/or his or her significant other, a s this offers insight into the patient's special needs and expectations. Documentation of meetings, individual patient care goals, and corresponding i nterventions improves consistency and accountability. This level of accountability more fully defines each clinician's responsibilities as well as commitments made by the p atient and/or family members. Education provided to ensure basic skills or competencies is imperative and has become a critical part of any care plan. C onsider having a process in place to identify learning needs. For instance, conducting a survey to determine the actual learning needs of clinicians might serve this goal. The value of a diverse, interprofessional team is that it provides a pool of experts to develop education and training. For example, suppose clinicians are seeking information pertaining to sensitivity. A social worker, chaplain, nurse expert, and patient member could develop a module to facilitate this education and training. Outcomes studies are essential to ensure long-term success and support. Economic and clinical data can be collected to measure the value of this organizational improvement effort. These studies should monitor both leading and lagging indicators. Economic and clinical outcomes are increasingly important as a result of pressure to achieve excellence status, as part of state or national mandates, or accreditation. An outcome indicator is considered information that can be used to predict and understand trends based on data. Two major categories of outcome indicators exist: leading and lagging indicators. The differences between these classifications of indicators rest in the predictions they make. 49 The importance of a lagging indicator is its ability to confirm that a pattern has occurred. Reduction of immobility-related consequences of care is one of the most common outcome indicators used to measure a bariatric effort. For example, a decrease in the frequency and severity of pressure injury is thought to signify safe, quality bariatric care. Conversely, if the frequency or severity of pressure injury increases, this assumedly suggests quality bariatric c are is deteriorating. Although lagging indicators are used to build performance dashboards and are often reported internally and elsewhere, they might not provide a ll the data necessary to craft a dynamic program. Leading outcome indicators signal future events. Leading indicators are often overlooked in a w orld where dashboards and economically driven outcomes are the measurements of choice. Leading outcomes indicators were once referred to as process o utcomes. Process outcomes measured those activities that supported the overarching clinical, cost, or satisfaction outcome. A leading indicator might be numbers o f individuals who have had sensitivity training or who are competent in using size-appropriate bariatric handling and mobility equipment. Time from admission to e quipment availability or time from admission to assessment by the BCT are both leading indicators that are designed to impact lagging indicators. These leading indicators predict future events, which can be measured using lagging indicators. Both of these complementary outcome measures are essential in monitoring success over time. Execution of the BCT at Waikato Hospital was associated with improving both leading and lagging indicators in the case study discussed. BCT AT WAIKATO HOSPITAL The BCT at Waikato Hospital was an innovation that emerged out of a need expressed by frontline staff members to better address bariatric patient care. In 2015 Jennifer Doms, a clinical nurse specialist at Waikato Hospital, reviewed organizational incident reporting related to bariatric patient care. The reports showed minimal evidence to support the concerns expressed by frontline staff. Georgina Temple, physiotherapist, suggested that limited reporting was likely related to individualized problem solving. Like many nurses, therapists and others, healthcare workers often have a "make-do" approach to complex patient care. In industry, this is referred to as "work-arounds" and in healthcare, this threatens the ability to achieve reproducible outcomes based on standardized procedures. 50–52 Ms. Temple identified a need to capture these care challenges formally, collect specific data on bariatric hospital admissions, and develop a human resource for staff members to consult. In collaboration with Ms. Doms, a project was developed to trial the role of a BCT. The team would assess individual patient needs, monitor their pathway, and f acilitate optimum patient care utilizing current hospital resources. The aim of the project was to identify systems and resources needed to improve the safety and q uality of care provided to larger patients. Key clinicians with experience in bariatric care were approached to support and join the project. Debbie Ford, occupational t herapist, Darnell Mercer, occupational therapist, and Michelle Tonks, physiotherapist, were members of the initial BCT. Allied Health Professional Lead (Lesley T hornley) provided supervision, but ultimately the group was self- established with no organizational mandate, and all work was completed in addition to current c linical roles. Executive interest in the bariaric care team was generated by the team sharing successes associated with the BCT with hospital g overnance committees and quality forums. In 2017, the BCT began the process for executive sponsorship. Once the BCT is formally recognized and has executive sponsorship, the next step will be to develop organizational level systems and resources to support staff members that includes a bariatric management plan; training packages; equipment management, such as labeling, purchasing, and rental packages; and further measurement of both leading and lagging outcome indicators. Although every facility will have a different structure within their unique organization, the key is to use models that have been successful. For instance, a BCT is to use a process for access similar to access to other resources, such as the wound care team, IV access team, and others. In the emerging Waikato model, criteria are being developed and will likely follow other clinical specialty resources. The goal for the BCT is to become a resource within the acute care facility that facilitates, in a timely manner, training and equipment in order to support the principles of early progressive mobility among individuals with morbid obesity or among individuals whose weight interferes with standard mobility tasks. DISCUSSION Standard healthcare policies and procedures might not serve the needs of the individual who is living with morbid obesity, as was observed during first hospitalization in the case study patient. Although this patient's only comorbid condition was type 2 diabetes, economic and clinical costs were significant. The BCT recognized opportunities to address these from the perspective of a single patient; however, the team created a f ramework from which to apply these economic and clinical benefits from a much broader point of view. The value of a BCT as the initial phase of planning and executing b ariatric care cannot be overlooked. The BCT at Waikato Hospital functioned as an interprofessional quality improvement effort comprised of interested and diverse p arties from several specialties. Like many bariatric teams across the country that address weight loss surgery or the general care for patients with morbid obesity, the t eam was designed to address ongoing issues and ideas. Although the BCT featured herein was comprised of therapy and nursing disciplines, a team could also i nclude the pharmacist, physician, wound care expert, and others. The inclusion of a patient representative is essential in that he or she understands the lived experience of b eing a larger, heavier patient. The BCT and the executive sponsors at Waikato Hospital believe that a coordinated approach was key to identifying the case study patient's complex size specific needs early, prioritizing his mobilization, and accessing the appropriate equipment as soon as possible in order to facilitate this. This process was thought to be the reason his second hospital admission was 1/6 the length of his first admission (11 days compared with 79 days), despite the more serious nature of his condition. CONCLUSION In the case presented, the BCT was successful in reducing the economic and clinical costs associated with the patient's acute care experience because of the timely and appropriate strategies, and access to proper equipment. As global awareness of the significant costs associated with caring for larger, heavier patients increases, healthcare facilities around the world can learn from the BCT model at Waikato Hospital. A strong interprofessional team with interest and enthusiasm for safe, quality care can serve to improve economic and clinical efficiencies in such a way as to overcome barriers associated with caring for individuals living with morbid obesity. REFERENCES 1. American Society of Metabolic and Bariatric Surgeons. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. https://asmbs.org/about/mbsaqip. Accessed May 17, 2017. 2. American College of Surgeons. America College of Surgeons and American Society for Metabolic and Bariatric Surgery Unify

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