December 2011

| January 18, 2012

by Robin L. Blackstone, MD, FACS, FASMBS

Dr. Blackstone is President of the American Society for Metabolic and Bariatric Surgery and Medical Director, Scottsdale Healthcare Bariatric Center, Scottsdale, Arizona.

ASMBS Mission Statement
The American Society for Metabolic and Bariatric Surgery was founded in 1983 to establish educational and support programs for surgeons and integrated health professionals. Our mission is to improve the care and treatment of people with obesity and related disease; to advance the science and understanding of metabolic surgery; to advocate for health care policy that ensures patient access to high-quality prevention and treatment of obesity. For more information, visit www. ASMBS.org. If you are interested in becoming a member or have questions about ASMBS, please contact Georgeann Mallory, the ASMBS Executive Director, via phone: (352)-331-4900 or e-mail: info@asmbs.org.

The American Society for Metabolic and Bariatric Surgery Center of Excellence Program—Time for Evolution.

The ASMBS has embarked on an evaluation of our current BSCOE program. Throughout the last 10 months, many of our colleagues have been working in ASMBS committees and sub-committees evaluating different parts of the current program and making proposals for an evolution of the program. Those proposals are now ready for member comment and input. The first installment details the history of the current quality programs in bariatric surgery. Once you have reviewed this information, we would appreciate your comments.
-Robin Blackstone, MD

Introduction: Purpose of the American Society for Metabolic and Bariatric Surgery (ASMBS), Bariatric Surgery Center of Excellence Program (BSCOE).

The original goals of the ASMBS BSCOE program are stated in an article authored by Ken Champion, MD, and Walter Pories, MD, published in Surgery for Obesity and Related Diseases (SOARD) in 2005: “The purpose of a COE program is to provide the means for the public and interested parties to identify programs in bariatric surgery that provide a comprehensive and standardized program of surgical care and long-term follow-up and management of the morbidly obese patients. The routine reporting and compiling of outcomes from bariatric surgical patients will provide an opportunity to assess and verify risks and benefits of therapy, which can potentially resolve many of the conflicts over the role of surgery in severe obesity. In addition, the COE program may challenge inadequate programs to improve their standards, education and training to meet the guidelines”.[1]

Recent data from the Nationwide Inpatient Sample demonstrates that bariatric surgery in-hospital mortality has decreased from 0.8 percent in 1998 to 0.1 percent in 2008[2] demonstrating that in regards to mortality the goal of improvement has been accomplished, there remain many areas that increasing patient safety remain.

The Process.

In order to fulfill our obligations of leadership in bariatric surgery safety, the ASMBS established a Quality and Standards Committee in February 2011 with broad representation of ASMBS Committee Chairs, designated representatives of the American College of Surgeons, the Michigan Bariatric Surgery Collaborative and the Surgical Review Corporation. The membership of that committee is listed in Table 1.

Robin Blackstone, MD, met with the Surgical Review Corporation in late March to discuss the committee and get their participation. At that meeting, it was decided that the responsibility for management of the data would be transferred to the ASMBS under the leadership of the Research committee. This transfer is now complete. The organizational document regarding this transfer led by Ranjan Sudan, MD, and Debbie Winegar, PhD, can be viewed at: http://bit.ly/ASMBS-dbm-transfer. Dr. Blackstone, Past President Bruce Wolfe, MD, and SRC BOLD database expert Debbie Winegar, PhD, met with John and Nancy Birkmeyer and Justin Dimick in August to understand the strengths of the Michigan Collaborative. Following that meeting, Dr. Blackstone met with the SRC, including Neil Hutcher, Medical Director for SRC, in-house council for SRC, Michael Hartney, David Provost, MD, Wayne English, MD, Debbie Winegar, PhD, Lynne Thompson, RN, Georgeann Mallory, RD, Executive Director ASMBS, in Raleigh, NC, to discuss the future direction of the program. There was wide consensus. In late August, Dr. Blackstone developed a white paper laying out the scientific arguments for change. This was widely circulated to the leadership and commented on and those comments adopted into the document. The ASMBS Executive Committee endorsed moving forward with the evolution of the quality program based on this document in September. In late September and October, a series of meetings took place with the American College of Surgeons (detailed below). Initial conversations regarding the direction of the program have been taking place with payors with enthusiastic endorsement of the direction of the program and the positive relationship with the ACS. Of note, the SRC is contractually prohibited from interacting with payors on behalf of the current program. In November and December, a series of webinar Town Halls were presented to a large segment of the leadership with broad consensus that the society is moving in the correct direction. To quote our founder, Ed Mason, MD, after attending one of the town hall meetings, “it is easy to gain consensus with the truth.” To view the slide presentation used in those town hall meetings please go to: http://bit.ly/ASMBS-THP A large group of your colleagues representing a broad spectrum of practice settings have been working hard for a number of months to establish the interlocking set of proposals that are being presented to the membership for public comment throughout the next few weeks.

Current Status of Programs.

American Society for Metabolic and Bariatric Surgery Bariatric Surgery Center of Excellence Program.

When the COE program was developed in 2004, the ASMBS established 10 standards by which facilities and surgeons would be evaluated as providing excellent quality of care in bariatric surgery. The BSCOE designation has become a commercially valuable designation, with some insurance payors, including the Centers for Medicare and Medicaid Services (CMS) requiring the designation in order to participate in their network of care.

The ASMBS and SRC entered into an initial six-year contract in 2004. At that time, the leadership of ASMBS believed that establishing a separate not-for-profit company to remain an arms length from the actual designation of programs would protect the integrity of that process.[1] The result, however, was that ASMBS had no direct control of the program. Although the committees at SRC were populated by bariatric surgeons were ASMBS members, the direct line to the leadership of ASMBS was not well established. Throughout time, this led to difficulties in communication, direction and oversight. A new five-year contract was renegotiated and executed in June 2010, during Dr. John Baker’s Presidency, establishing a clear new relationship between the ASMBS and SRC. SRC manages the application process, site visits and the collection of data in BOLD. ASMBS is responsible for establishing the guidelines and direction of the program as well as directing the use of BOLD data through the ASMBS Research, Data Access and Data Dissemination Committees. All proposals for the use or release of data from BOLD are required to come through these committees. The SRC has established other programs including the International Center of Excellence (ICE) program, and the American Association of Gynecologic Laparoscopists (AAGL) Center of Excellence program. SRC has the contractual authority to develop other programs, although the resources of the ASMBS BSCOE program are segregated financially from the use in other programs. The ASMBS also has the contractual ability to establish new programs.

American College of Surgeons Bariatric Surgery Center Network (ACS BSCN).

In a parallel effort, the American College of Surgeons established their own Bariatric Surgery Center Network (BSCN), with somewhat similar standards and reporting requirements. This equivalent effort, rather than a collaborative one, resulted largely from a disagreement between ASMBS and ACS regarding the need for outside stakeholders to participate in the executive direction of the program by being part of the SRC board and the use of a third party (SRC) to administer the program instead of partnering directly with the college. It is the position of the ACS that the specialty society (ASMBS) is best able to determine what constitutes quality in our field.[3] Throughout the seven years, the composition of the SRC board has changed and no longer reflects a strong bariatric surgeon presence. An examination of the ACS BSN program shows some philosophical and practical differences between ASMBS and ACS:
1.    The control and direction of the program by ACS remains solely with ACS without involvement of a third party.
2.    The ACS program requires certification of the hospital and has no requirement regarding individual surgeon volume or certification of surgeons individually (this data is hard to collect because a surgeon may practice at multiple sites).
3.    The site visits are performed by surgeons instead of nurses as in the ASMBS program.
4.    The burden of data collection and accuracy in the ACS program rests with the facility instead of being placed on the individual surgeon/practice.

Finally, in an effort to provide a solution for low volume programs, the ACS BSN evolved to include a Level 2 designation for programs with lower volumes of cases within a specific window of risk adjustment requirements.

As of October 2011, the ACS BSCN reported a total of 137 programs at the October Bariatric Surgery Committee meeting including the following:

There is no evidence that an arms length relationship is necessary to establish credibility with outside stakeholders. In fact, the ACS program is accepted by all payors similar to the ASMBS program. The issue of whether independence from the process is necessary is a crucial question in any future program the ASMBS may develop.

The Michigan Bariatric Surgery Collaborative (MBSC).

The MBSC (2006) is a voluntary group of hospitals and surgeons performing bariatric surgery in Michigan organized with a goal to decrease complications from bariatric surgery. The Northern New England Cardiovascular Disease Study Group pioneered the model that was adapted in Michigan. The model has three major components:
1.    A clinical registry with rich enough detail to allow for robust risk adjustment.
2.    Hospitals and physicians receive risk adjusted and confidential feedback.
3.    Hospitals and surgeons convene to review and interpret the data, identify best practices and implement them across the region.[4] The actual process for implementation is done on the local level based on the resources available.

This model was adopted in the State of Michigan in partnership with Blue Cross Blue Shield (BCBS) of Michigan (47 percent of covered lives in Michigan) that funds the central administration of the program and reimburses surgeons/facilities to enter the data. The data are confidential and not accessible to BCBS. Participating hospitals submit data to the registry and meet three times per year to examine the data and to design and make changes in patient care. Approximately 6,000 to 8,000 patients per year participate in the program and all but one bariatric program/surgeon in the State of Michigan participates.[5] The MBSC meets three times a year to share data and determine targets for CQI. The serious complication rate in Michigan has declined from approximately 5 to 2.5 percent in the most recent publications, a result that is directly related to the programs CQI initiatives.[6] The incidence of serious complications was unrelated to whether a program was an ASMBS BSCOE. This prompted BCBS to remove the requirement that programs in Michigan had to be a part of the ASMBS BSCOE in order to operate on BCBS patients. Members of the leadership have attended the MBSC collaborative meetings and spoken with the surgeons involved. Even surgeons who were initially skeptical or reluctant have come around to be supportive. One surgeon said “quality and performance are going to drive our collective future, it is nice to have guidance and ownership in the process.” The strength of the program revolves around the integrity and quality of the data.

Why does the ASMBS BSCOE need to evolve? Since 2004, the national conversation about quality has continued however our program has not evolved to include current, state of the art concepts in quality. Data show that measuring outcomes using risk-adjusted and reliability adjusted composite quality measures may be more efficient at predicting quality than volume or risk adjustment alone. Other reasons to evolve the program include an apparent plateau of the number of procedures throughout the last four to five years,[7] an increase in cost for management of complications and financial pressures on hospitals/surgeons and the healthcare system to perform even the most complex operation with low mortality and morbidity. Payors (insurance companies and employers) are interested in identifying and sending their insured/employees to programs that will perform operations with the best outcomes and the lowest complication rates. Patients are using the Internet to participate to a greater extent in choosing their surgeons/programs. Public reporting has changed the landscape of healthcare creating pressure for greater transparency in outcomes and will be required in 2014. Some outside parties, like HealthGrades, are using administrative databases with poor risk adjustment capability to offer their opinion of programs and individual surgeons.[8] Better outcomes are being linked to pay for performance through the National Quality Forum. Future reimbursement through a pay for performance system of care may require the ability to predict quality and control of costs associated with care and finally surgeons who practice both general surgery and bariatric surgery will be required to report all of their surgical procedures for maintenance of certification.

In this changing environment, the question that arises is what is the ASMBS’s current goal in identifying centers of excellence? Are we establishing a threshold of quality that is an acceptable minimum standard? Are we trying to determine which programs offer the best care? Or are we trying to provide a platform for process improvement? Some additional observations about the current quality construct that motivate the society to move forward with changes are:
•    The current accreditation process for the BSCOE utilizes a volume requirement as a proxy for quality. Evidence is accumulating that volume may have been overstated as a predictor of performance especially in procedures where the mortality rate is low, like heart surgery and bariatric surgery. It is not as good a predictor as composite measures, which include volume as a part of the signal, but also include other parameters of quality.
•    The current accreditation process is not able to predict the performance of any given designated center. Using the current quality matrix, we survey programs based on structural and process elements only, not on outcomes. This means we may include centers in our certification that do not have good outcomes or exclude ones that do. This has been noted in publications and by payors. Some payors, like Blue Cross Blue Shield (BCBS) of Michigan and Leapfrog have moved away from designation of a program as an ASMBS program to qualify as a provider in their network.
•    The current program excludes some bariatric surgeons from participating either due to volume, coverage or structural/process requirements. Some programs that could qualify previously, may not qualify in the future if their volume drops.
•    The accreditation process has not evolved to provide regular risk adjusted reporting back to programs/surgeons so that process improvement can occur.
•    Interpretation of the original 10 requirements as they were applied to individual facility/surgeon situations has added layers of structure and process resulting in further expense to programs. The extent to which these requirements impact quality and patient safety is unknown.
•    The ASMBS established an “ASMBS Fellows Program” during Harvey Sugerman’s presidency, in which any member of ASMBS could submit their outcomes data to the ASMBS BSCOE Database (BOLD) database. This aspect of the program has been under-subscribed and minimally utilized, such that it has not accomplished the intended function of determining whether the lower volume minimum surgeon/hospital criteria should be revised.
•    Members of ASMBS do not clearly understand the role and responsibility of ASMBS in the current program. It is difficult for the society to achieve accountability with a third party administrator.
•    The current existence of two quality programs (ASMBS BSCOE and ACS BSCN), with different standards, creates confusion for surgeons, facilities and payors and duplicates effort. In a digital age, the infrastructure necessary to administer the programs may decrease the overall cost of the program if consolidated.
•    Surgeon credentialing has been developed by three different societies with different recommendations.

This concludes the introduction to the series of proposals that you will have an opportunity to comment on.

HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems.

Each of us working within a facility will need to be aware of and adopt a systematic approach to get patient feedback on our level of service. Regardless of how you may feel about this politically, this is the new reality of our practice of medicine, and by understanding and using the information that is gained, we may improve the level of service and decrease the complications and our liability for dissatisfaction. The focus of this section will be on the surgeon’s role in improving the patient’s experience.
In 1999, the Institute of Medicine (IOM) published a landmark document entitled, “To err is human.”[9] This was followed by another publication, “Crossing the quality chasm.[10] Both of these documents point out that many deaths occurring in hospitals are preventable. This gave rise to the birth of the quality movement and focus on preventable surgical error. Three areas have subsequently been identified by the IOM for improvement: 1) patient-centered care, 2) healing relationships, and 3) alignment of payment. The Centers For Medicare and Medicaid (CMS) decided to hold back monies from facilities unless they adopt a formal assessment system of provider care (HCAHPS) and the facility has to perform at a certain level to get those monies back. Finally, the Affordable Care Act has reinforced the movement toward public reporting and transparency. This is an effort to improve the value (quality/cost) of medical care to patients.  Two key papers detailing the patient point of view are “Through the patient’s eyes”[11] and “Achieving an exceptional patient and family experience.”[12]

The HCAHPS process is fundamentally different from patient satisfaction surveys. Satisfaction surveys are almost always positive and yield very little actionable data for providers. The new concept is to assess the patient experience related to caregiver behaviors and provide actionable results.

Quint Studer, former CEO of 800-facility Baptist Hospital group and a recognized leader in driving high-quality patient experiences, says that physicians who understand and engage in behavior that results in high-quality patient experiences are sued less frequently, have better clinical adherence with treatment regimens, have lower 30-day readmission rates, and have better patient perceptions of care.

The questions about physician care on the survey are as follows:
1.    During this hospital stay, how often did doctors treat you with courtesy and respect?
2.    During this hospital stay, how often did doctors listen carefully to you?
3.    During this hospital stay, how often did doctors explain things in a way you could understand?
Survey participants can answer with either Never, Sometimes, Usually, and Always. Only the response “Always” qualifies for reimbursement.

In order to achieve an “Always” response the following behaviors are recommended:
•    Knock before entering room.
•    Make eye contact.
•    Greet the patient and address them by name.
•    Introduce yourself with your role and experience (especially if seeing someone new).
•    Ask permission to begin exam or assessment.
•    Sit when possible (time spent overestimated by patients by 1.3 minutes [e.g., “I have time for you”]).
•    Tell patients when they will see you next
•    Strengthen nurse/physician relationships (patients recognize disjointed communication).
•    Teamwork: Share positive information about other care providers on the team.
•    Use reflective listening (paraphrase [e.g., “I want to be sure I heard you”]).
•    Practice empathy: active listening with the 60/40 rule—listen 60 percent; talk 40 percent.
•    Explain diagnosis in clear, simple language.
•    Explain medications: name, purpose, how long taken, potential side effects.
•    Explain diagnostic testing: How long will it take? Will it be painful or uncomfortable?
•    Share recommendations for treatment; What will happen next?
•    Ask patients and families what role they want in decision making.
•    Share plan of care with patient/family and nursing team.
•    Identify coordinating physician for the medical team.
•    Include the family in rounds.
•    Use white board to communicate physician names.

In terms of improving quality, embracing these practices within your everyday course of work may improve your own feeling of satisfaction with your work, decrease your liability, and enhance the relationships of the whole team working for the safe and effective care of patients.

Preview of the ASMBS Annual Meeting.

The last independent meeting of the ASMBS, before we merge our meeting with The Obesity Society in a joint meeting called Obesity Week, November 2013, will take place in San Diego, California, June 17 to 27, 2012. Many of the surgeons and integrated health who have been coming to our meeting for many years will want to take part in this last historic and pivotal meeting.

The Program Committee, led by Dr. Ninh Nguyen, has been working very hard to assemble an outstanding program of original articles, expert videos, and educational symposia/labs that will provide our membership with an outstanding experience. One of the key themes of the meeting is to understand the Biology of Obesity and the connection to the metabolic and bariatric procedures that we perform and how these procedures affect obesity in a neurohormonal way. The postgraduate courses and integrated health sessions start on Sunday, June 17, 2012. The committee meetings will take place primarily on Monday and Tuesday. Please check with your committee chair to find out when your meeting will be scheduled. You will want to make reservations early since the meeting is expected to be sold out. The main plenary session begins on Wednesday, June 20, 2012. In addition, on Wednesday afternoon a presentation by Past President, Dr. Bruce Wolfe on the new NIH Guidelines followed by a Town Hall with President Dr. Robin Blackstone on the changes in the ASMBS Quality program will be featured. The Mason speaker this year is Dr. John Birkmeyer who will speak on Surgical Quality followed by the President’s address on Thursday. The week will be capped off on Friday, June 22, 2012 with the first National Bariatric Quality Forum. Every ASMBS Quality program coordinator and medical director is invited to learn about the specifics of the new quality matrix and receive their first composite scores and risk-adjusted data. More information about this forum will be coming out in early spring. The ASMBS Quality and Standards committee will also announce the first quality-improvement project for 2012.

San Diego is an excellent location for families to enjoy a variety of fun attractions and fabulous food while you are hard at work getting up to date on the latest information in our field. Check out the ASMBS website (www.asmbs.org) to see the program and to register and make reservations for the meeting.

References
1.    Champion JK, Pories WJ. Centers of Excellence for Bariatric Surgery Surg Obes Relat Dis. 2005; (2): 148–151.
2.    Nguyen NT, Masoomi H, Magno CP, et al. Trends in use of bariatric surgery, 2003–2008. J Am Coll Surg. 2011;213:261–266.
3.    Birkmeyer JD, Shahian DM, Dimick JB, et al. Blueprint for a New American College of Surgeons: National Surgical Quality Improvement Program. J Am Coll Surg. 2008:207(5).
4.    O’Connor GT, Plume SK, Olmstead EM, et al. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting: the Northern New England Cardiovascular Disease Study Group. JAMA. 1991; 266(6): 803.9.
5.    Share DA, Campbell DA, Birkmeyer N, et al. How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care.  Health Affairs. 2011:30(4).
6.    Finks JF, Kole KL, Yenumula PR, et al. Predicting risk of serious complications with bariatric surgery. Ann Surg. 2011;254(4):633–640.
7.    Livingston EH. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010;200(3):378–385. Epub 2010 Apr 20.
8.    Bariatric Surgery Trends in American Hospitals. HealthGrades. 2011.
9.    Institute of Medicine Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. 2000. www.nap.edu/catalog/9728.html. Accessed December 6, 2011.
10.    Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. www.nap.edu/books/0309072808/html. Accessed December 6, 2011.
11.    Gerteis M, Edgman-Levitan S, Daley J, et al, eds. Through the Patients Eyes. 1993. www.nejm.org/doi/full/10.1056/NEJM 199403243301225. Accessed December 6, 2011.
12.    Balik B, Conway J, Zipperer L, Watson J. Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. www.camcinstitute.org/university/pdf/IHIPatientFamilyExperienceofHosp italCareWhitePaper2011.pdf. Accessed December 6, 2011.

Category: ASMBS News and Update

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