This column is dedicated to sharing the vast knowledge and opinions of the American Society for Metabolic and Bariatric Surgery leadership on relevant topics in the field of bariatric surgery.
This month: An Update on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)
David Provost, MD
Medical Director, Bariatric Surgery, Texas Health Presbyterian Hospital of Denton, Denton, Texas; Past President of the American Society for Metabolic and Bariatric Surgery Foundation
Bariatric Times. 2015;12(10):24–26.
Dr. Rosenthal: Please tell us how you became involved in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.
Dr. Provost: I was initially involved with the Bariatric Surgery Centers of Excellence (BSCOE) Program when the American Society for Metabolic and Bariatric Surgery (ASMBS) contracted with the Surgical Review Corporation (SRC) to provide accreditation. I joined the program’s Bariatric Surgery Review Committee (BSRC) in 2005, prior to the Centers for Medicare and Medicaid Services (CMS) approving coverage for bariatric surgery and requiring that all surgeries be performed at COE facilities.
In 2009, I became Chair of the BSRC. In 2012, the ASMBS terminated their contract with the SRC and signed a memorandum of agreement with the ACS, thus forming a unified accreditation program called the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
As BSRC Chair, I was involved in this merger and the program’s early drafts. Since the formation of MBSAQIP in April 2012, I have served on the Committee on Metabolic and Bariatric Surgery (CMBS) and as Co-Chair of the Verifications Committee.
Accreditation and quality are very important to me. I believe that with the initial BSCOE program and now with the MBSAQIP, we have had a major impact on improving outcomes for bariatric surgery. The original program emphasized processes and ensured they were in place in order to provide the best possible outcomes. Now, we have the ability to also include quality improvement and look at risk-adjustment outcomes in order to further improve bariatric surgery provided in facilities around the United States.
My current center has been accredited since 2009. We are scheduled to have a site visit this Fall for re-accreditation.
Dr. Rosenthal: How does the MBSAQIP accreditation process work?
Dr. Provost: In order for a center to be accredited, it must complete all required paperwork and pass a site survey. We have over 70 surgeons who perform site visits to ensure a program is adhering to the MBSAQIP standards. During these visits, the site surveyor meets with the medical director, bariatric program coordinator, and clinical reviewer for a tour of the facility, including chart review and one-on-one interviews From there, the surveyor submits a detailed report of the visited center. Two surgeon reviewers, members of the MBSAQIP Verification sub-committee and other CMBS committees, review the report. If there are any discrepancies between the determinations of the reviewers and site surveyor, the report is reviewed in a final adjudication meeting with the Co-Chairs of Verification and the CMBS co-chairs. As Co-Chair of the Verification Committee, I meet almost weekly with the other adjudicators to discuss the status of facilities up for re-accreditation that are in discrepancy. Any programs that do not initially “pass” are then given the opportunity to correct their deficiencies in a reasonable time frameto achieve accreditation. We try to help accredited programs to stay accredited and new programs to become accredited. Retention is good for the facility, the patient, and the MBSAQIP program.
Dr. Rosenthal: How does the MBSAQIP assign and train site surveyors? How do they communicate MBSAQIP standard changes to site surveyors and facilities?
Dr. Provost: When assigning surveyors to sites, we try to assign someone who has no potential conflict of interest (e.g., a surgeon from a neighboring or competing center). We try to get someone from outside the immediate area to conduct a site visit. I think this is very important so that there is no perception of bias.
A site survey is something that a facility must be prepared for, but it’s not meant to scare them. It’s an opportunity for positive and negative feedback for both the facility and MBSAQIP program. Ultimately, it is a positive event because it helps the facility look at ways in which they can improve their bariatric program.
We have a very active training program for site surveyors. We have monthly calls and webinars to relay any changes in the processes for surveys. Also, the programs have the opportunity to evaluate the surveyors and site visit. So, we are getting feedback from the programs, which help improve the process for everyone.
Additionally, we host webinars to relay information and answer questions from centers that are either accredited or in the process of accreditation.
Dr. Rosenthal: How about live training events? Do you have any programs scheduled on MBSAQIP during Obesity Week 2015?
Dr. Provost: We do have presentations and live training sessions during the major bariatric scientific meetings, including Obesity Week 2015, November 2 to 6, 2015 in Los Angeles, California. On Monday, November 2, 2015, we are hosting two courses on MBSAQIP. “MBSAQIP: Lessons Learned and Best Practices from the Field” will take place 1:30pm to 5:30pm PST in the Los Angeles Convention Center (LACC), Room 403A. Here, people who have already had their site visits will talk about their experiences. They will discuss how they prepared for the visit, details of the visit, and what they learned from it, including what they were already doing well and areas of improvement. I think it will be a nice course for those awaiting their site visit, as they will get to hear from people who have been through the process.
We are also hosting the “MBSAQIP Clinical Reviewers Course,” Monday, November 2, 2015, 8:00am to 5:30pm PST, LACC, Room 408B. This course is designed for both surgeons and integrated health professionals.
Dr. Rosenthal: What are the numbers to date? How many centers are accredited through MBSAQIP? How many site visits have you performed this year?
Dr. Provost: As of October 19, 2015, there are 795 hospitals participating in the MBSAQIP program. The breakdown is as follows: 652 accredited hospitals, 37 data collection centers, and 106 initial applications in process. Since the MBSAQIP rollout, 255 centers have been accredited.
As of September 25, 2015, we have done 335 site visits and we have more scheduled. Over the course of one year, we have performed over 300 visits. This is more than any accreditation program of the ACS has ever performed. We set the record this year, our very first year of site surveys, and I’m very proud of that. Everyone has worked really hard.
Dr. Rosenthal: Has the June 2013 CMS decision to not require that bariatric surgical procedures be performed at an accredited center impacted the accreditation program? Have you had fewer programs apply or accreditation or re-accreditation?
Dr. Provost: We have had very few programs drop out since the ASMBS/ACS merger and CMS decision. The majority of programs that have dropped out have done so because their facility no longer has a bariatric program, not because of the CMS decision. MBSAQIP developed new volume standards that make participation more attainable for lower volume centers. We’ve heard from a lot of new centers that want to participate in MBSAQIP.
I think people understand that accreditation is important and positive. While CMS dropped the need for mandatory accreditation of a program, many of the managed care players (e.g., Blue Cross, Blue Shield, Aetna, Cigna, and United Healthcare) have continued to require accreditation for bariatric surgery coverage, depending on the patient’s insurance plan. Many of the payers now have their own accreditation programs. For instance, Blue Cross, Blue Shield has the Blue Distinction Specialty Care recognition program. So, it’s made it difficult for bariatric programs as they may be undergoing inspection for accreditation for not only the MBSAQIP, but also the other individual payer programs.
We have been working on getting the individual payers to allow us to do their accreditations. We have made some progress on this initiative. Many of the individual payer accreditation programs examine cost in addition to standards, and designate approvals based on largely on a facility’s costs. It’s a very complicated process and we are hoping to simplify it.
Dr. Rosenthal: What other progress has MBSAQIP made?
Dr. Provost: There are four subcommittees of MBSAQIP:
1. Standards: Responsible for the development of new joint accreditation standards.
2. Verification: Validates and certifies that each individual center meets accreditation criteria.
3. Data Registry and Reporting: Oversees the data registry and provides input on analytical and reporting tools to support the needs of the joint program.
4. Quality: Responsible for all activities and initiatives that involve performance improvement, collaborative work, and the sharing of best practices.
The Data Registry and Reporting sub committee has succeeded in getting the MBSAQIP data registry approved as a qualified, clinical data registry (QCDR), which gives surgeons the opportunity to use the data to meet meaningful use requirements of CMS.
The Quality sub-committee, which is the newest sub-committee, has been working to help programs with their quality improvement efforts. They have also been working on the design and implementation of national quality improvement projects in bariatric surgery. The first project—a study called Decreasing Re-admissions through Opportunities Provided or DROP—is in progress right now. The second program, which is under design, will be looking at enhanced recovery after bariatric surgery.
All the sub-committees are really working to improve the process and provide more benefits to accreditation, which will ultimately improve the overall quality of bariatric surgery.
We have also made progress in working with the individual payers. We’ve gotten many to accept our accreditation, but they still want to look at other areas, such as outcomes and costs.
Dr. Rosenthal: Have there been any recent studies on bariatric program accreditation and its impact on patient care or outcomes?
Dr. Provost: Despite the CMS decision, we continue to see evidence that accreditation in bariatric surgery does matter.
In 2014, a study by Gebhart et al found the accreditation in bariatric surgery was associated with a more than a than-fold reduction in risk-adjusted in-hospital mortality. They concluded that resources established for bariatric surgery accreditation may have the secondary benefit of improving outcomes for patients with morbid obesity undergoing general laparoscopic operations.
Most recently, Telam et al evaluated the impact of national hospital accreditation on perioperative and long-term outcomes following bariatric surgery. They found that, in New York State, bariatric hospital accreditation improved patient outcomes as compared to nonaccredited hospitals. They concluded that significant changes were identified for some underserved at-risk populations and measures to ensure equitable healthcare for at-risk populations following institutional accreditation are imperative.
Dr. Rosenthal: How do programs apply for accreditation through MBSAQIP?
Dr. Provost: Interested programs may learn more and apply for accreditation on the MBSAQIP website, http://www.mbsaqip.org. Here, they can access a copy of the current MBSAQIP standards and fill out a pre-application form. From there, they can register, enter the application portal, and begin the application process. After the application is complete, they can begin training their clinical reviewer and start entering their facility’s data in the database. They are also assigned a date for their site visit and a site surveyor. The site visit typically takes place within six months of the application submission.
Beginning in January 2016, we will be offering the opportunity for programs to apply as “data collection centers.” So, smaller volume programs that may not meet volume requirements or feel they are not ready to apply for full accreditation will still be able to enter their cases into the data registry. We have an extensive FAQ section on the website to help answer any questions about the accreditation process, fees, and data registry.
We don’t actively recruit programs to apply for accreditation except during national meetings when we host courses on MBSAQIP. These courses are geared toward talking about the positives of being an accredited program and helping those programs that wish to apply for accreditation.
Dr. Rosenthal: What are the benefits of being an accredited bariatric center?
Dr. Provost: I think there are a lot of benefits both for the program and the patient. I believe that accreditation through MBSAQIP provides reassurance to the patient that your program is committed to good outcomes. It helps with getting into the various managed care accreditation programs. Accreditation also shows that you’re accountable and your center desires to maintain the highest level of care according to national standards not only from a patient care standpoint, but also for outcomes monitoring and continued quality improvement.
Also, the MBSAQIP data registry allows you to compare your results with the national standards. Twice a year, we do a risk-adjusted report that takes into account patient acuity and other major risk factors. This gives you a good idea of how you are doing in relation to national averages and outcomes. It also gives a program the opportunity to identify areas for quality improvement. For example, if you find you are in the lower quartile for wound infections or re-admissions, then it gives you an area in which to focus more of your efforts.
It is a lot of work, but it is worthwhile.
Dr. Rosenthal: Thank you for providing a comprehensive update on the MBSAQIP.
1. Gebhart A, Young M, Phelan M, Nguyen NT. Impact of accreditation in bariatric surgery. Surg Obes Relat Dis. 2014;10(5):767–773.
2. Telem DA, Talamini M, Altieri M, et al. The effect of national hospital accreditation in bariatric surgery on perioperative outcomes and long-term mortality. Surg Obes Relat Dis. 2015;11(4):749–757.
Funding: No funding was provided in the preparation of this manuscript.
Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.