ASMBS News and Update—May 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.
The ACS-ASMBS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBS AQIP) rolls out the new e-Toolkit. Over the last few weeks, all programs recognized by the American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence (BSCOE) program as either Fully Approved or Provisional have received a notice, including the e-Toolkit, that they need to enroll their program in the new unified quality program. The e-Toolkit was sent to the facility, not to the surgeon’s individual office. The e-Toolkit contains all the agreements and information to bring your program into compliance with the new, unified designation and is fully automated. Each e-Toolkit is unique to the program that receives it, so you will need to get it directly from the administrative team at the American College of Surgeons led by Amy Robinson-Gerace. In order to maintain accreditation, all programs must be qualified and entering their data in to the unified program registry by May 31, 2012. All data from March 1, 2012 will be required.
If your program has not received the e-Toolkit and you believe you are eligible, please contact Amy Robinson-Gerace, the administrator for the unified program at: [email protected]

First Annual Metabolic and Bariatric Surgery Quality Forum will take place on Friday, June 22, 2012 from 10:30am to 12:30pm. This is a critical forum for all surgeon medical directors and program coordinators to attend. The program will discuss the data that have been returned from the ASMBS BSCOE registry, the ACS Bariatric Surgery Center Network (BSCN) registry, and set forth the quality initiatives for the society for 2012/2013.

• The Challenge of Achieving Patient Safety
Robin Blackstone, MD, FACS

• Presentation of Data from the ASMBS BSCOE Data Registry/How to interpret your data
Ranjan Sudan, MD, Chair of the ASMBS Research Committee

• Presentation of data from the ACS BCSN Data Registry/Outcomes Based Reports
Matt Hutter, MD

• How to Use Collaboratives in Quality Improvement: Planning for Future Safety
John Morton, MD

• Integration of the new Credentialing guidelines into your practice environment
To Be Announced

• MBSC VTE/Filter Quality Improvement Project
Oliver Varban, MD, Michigan Bariatric Surgery Collaborative

• Setting a course for the future of patient safety
Robin Blackstone, MD, FACS, FASMBS

For those programs unable to send their surgeon medical director or bariatric coordinator, the program will be webcast live from the lecture hall.

The ASMBS will issue the third Annual Report during the Annual ASMBS Meeting. The annual report was established by then Secretary-Treasurer, Robin Blackstone, and supported by the Corporate Council as a way for the membership to have a written record of the work took place by the society over the previous year. The Annual Report is given out to members as they enter the business meeting, which will take place on Thursday afternoon, June 21, 2012. It is available online and through the ASMBS website.

Question about the unified Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.
by Robin Blackstone, MD and Ninh Nguyen, MD

In the evolution of the ASMBS BSCOE program, it is important to realize the timeline of events. In November of 2010, a comprehensive review of the ASMBS BSCOE program was done. This resulted in the formation of the Quality and Standards Committee (QSC) in February of 2011. The QSC has a broad representation from the ASMBS committees, the American College of Surgeons, the Michigan Bariatric Surgery Collaborative and the Surgical Review Corporation. The QSC determined that establishing a combined program with the ACS so that one standards in Metabolic and Bariatric Surgery could result was a high priority. Throughout this process of transition the leadership has been engaged in multiple avenues of communication and feedback from the membership. Since the new unified program has been formed with the ACS, some questions have come up about specific decisions regarding the new program. I am going to use this space to provide some answers to these questions.

Individual Surgeon BSCOE certification—why its time has passed in MBS. Throughout the last seven years of the ASMBS BSCOE program, both the facility and the surgeon had to seek accreditation separately from one another. This system reflects an earlier era in surgery where the private practice surgeon was often somewhat “at odds” with his or her facility. In the early days, the “practice” was also accredited. Surgeons were charged separately from the facility and the individual surgeon office was responsible for submitting the data to the system. Over the last 18 months, as the Quality and Standards committee began to look critically at the ASMBS BSCOE program, the certification of individual surgeons was evaluated as a problematic area of the program. When the ASMBS decided to terminate our relationship and align the program with the ACS to achieve one standard in our specialty (supported by unanimous endorsement of the Executive Council and the Board of Regents), we had to examine each of our own criteria to determine how we would incorporate the two programs moving forward. It was at that time that we reexamined, in detail, the certification of surgeons and their practice. ASMBS was the only specialty in all of the quality programs that exist in the United States, including trauma, thoracic surgery, and oncology or programs that are accredited by outside agencies (JACHO) or the government (CMS) that accredit individual surgeons. At the heart of the issue is the difference between credentialing and accreditation. The credentialing of individual surgeons is the responsibility of the medical staff that practice at a facility. The credentialing committee is able to verify the education, training, ethics, and behavior and malpractice status of the surgeon in order to grant him or her credentials.

Clearly it was necessary to revise the ASMBS recommended credentialing guidelines as part of the process to transition away from individual surgeon accreditation. The ASMBS credentialing guidelines were last revisited in 2005 and the ACS and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) had different guidelines. A joint task force between the three societies was formed and led by Barry Inabnit, MD, and the first draft of the proposed guidelines published in December. The final draft will be forthcoming for public comment and society review in the next few months.

Some of you have asked how the new accreditation will handle the question about whether a surgeon who only places the adjustable gastric band is equivalent in scope of practice to the surgeon who is doing complex revisions and advanced procedures in a high-risk population. This question and debate has raged for years and been discussed widely. This question is a good example of how this type of issue (i.e, which procedures and under what conditions they can be performed at the facility) be answered best at the local level with input from the surgeons practicing at that facility. In other words, this is a matter best addressed through credentials at a local facility rather than for accreditation. Establishing adequate credentials the responsibility of the surgery department in each facility (i.e., a function of the medical staff and not of the facility administrative personnel [CEO, CFO, etc.]). Credentialing will be the most important way for individual surgeons to assure that they are being treated fairly.
In the discussions with surgeons about this issue, the following three prevailing themes have come up: 1) The surgeon sees the designation as an economic advantage and is concerned about losing the advantage if other surgeons at the same facility are not included, 2) Surgeons have concerns about losing autonomy and control if the hospital collects the data, and 3) The “portability” of the designation (i.e. being able to move from facility to facility) as easily.

ASMBS BSCOE accreditation clearly has commercial value that is a byproduct but not the reason for its existence. Surgeon reputation is the most important single factor in developing a robust practice, but the overall reputation of the facility is also important. Having all surgeons included will mean that the overall quality of surgery will be improved and the group has a chance to develop more collegiality and support for each other in the program. The hospital already has the data on individual surgeons. In fact, being more involved with the hospital to assure they are coding your cases correctly and reporting them correctly will be an important working model as we move forward to bundled payments and other new ways of gaining reimbursement for our work.

In regards to establishing new programs, the facts are that moving to a new facility under the current program has been extremely difficult and problematic because of the volume requirement rather than COE status. The old paradigm of accrediting surgeons did not help establish a new program. Efforts to facilitate that by the former administrator led to an unsanctioned practice called “fast tracking” that was not approved by insurance companies or the Centers for Medicare and Medicaid Services (CMS) and placed programs at a high-liability risk as well as the risk of non-reimbursement by CMS and other payors.
The additional issues involved with individual surgeon accreditation are:

• Data from surgeons practicing at multiple facilities cannot be accurately verified.

• CMS recognize accreditation of centers only—never individual surgeons.

• The previous system created a competitive environment that is not conducive to patient safety— between surgeons and surgeons and facilities.

• Accreditation of surgeons can place the accrediting body (ASMBS or ACS) at additional risks for liability in a malpractice suit, especially in a volume-based accreditation program where you are not accrediting based on outcomes. The ASMBS, but not the ACS, has been involved in litigation from this specific issue.

• Accreditation of facility closes an important “loophole” of quality by requiring all data from the facility to be reported on all surgeons, rather than only the surgeons who are designated.

• Facilities in general have more resources to provide the data for the initial hospitalization, readmissions, and reoperations. As the facility is responsible to collect long-term data as well, it will require a cooperative relationship, but the cost of collection will be borne primarily by the facility.

• Collaboration around accurate coding of cases will be critical for the surgeon to be fairly represented by the data. Surgeons will have access to their own data in the registry so they are able to confirm and review reported adverse events to make sure the coding is correct. This establishes a more collaborative process and one in which the leadership of the medical director surgeon will become essential

• The institutional credentialing committee is better suited to accredit a surgeon based on his or her outcomes, board certification, volume of cases, and criminal background check. This must be done at the local level. National accreditation administrators do not have the manpower or the mandate to do this task.

In the new environment of clinical integration, patient safety, experience, and effectiveness of treatment will all be measured and reported. The ASMBS will lead that effort in MBS and the surgeon members of our society will need to lead this on the local level. The ASMBS is committed to giving our surgeon and integrated health members the tools they need to lead their facilities in MBS quality through our education programs and accreditation process.

Integrated Health in the new Quality Paradigm. The essence of what distinguishes our specialty approach to the metabolic and obese patient is the essential inclusion of integrated health colleagues in the pathway of care. Our society membership reflects this commitment strongly (Figure 1). MBS differs from general surgeons who provide “episodes” of treatment for a defined disease state, like an appendectomy or cholecystectomy. This is contrasted with working in a chronic disease model like obesity, which requires a long-term relationship with the patient and an multidisciplinary team approach. The typical accredited ASMBS MBS program requires that nutrition and psychological colleagues participate in the evaluation and ongoing care of our patients. Mid-level providers (Nurse Practitioners and Physician Assistants) as well as Bariatric Coordinators also support the pathway of care and are often key components of the patient experience. In fact, increasingly, certified bariatric physicians and exercise physiologists will also participate either as independent practitioners in the preoperative and longer care of our patients or perhaps even more closely aligned with us as part of an integrated team model. The long-term care of the MBS patient in mature programs usually is the responsibility of these other members of the team rather than the surgeon in a continuum of care model.

So, what are the obstacles for continuing to provide true programmatic care? One of the issues that plague many programs is the lack of reimbursement for these support personnel. In the past, the program made enough revenue from the surgical procedures to fund the salaries of these critical personnel, however, in the upcoming era it is unclear how that will be “bundled” into the single fee that will be paid to hospitals for the entire episode of care. Therefore, it is essential that we develop an evidence basis that supports the necessary participation of the integrated team in the pathway of care of our MBS patients. It is only through the further development of this evidence basis that we will be able to continue to fund integrated program personnel.

Multiple domains of quality will be assessed in the new accreditation program. In addition to surgery-driven adverse events at initial hospitalization and 30 days, long-term effectiveness that may be a better reflection of the team’s effort with patients will also be followed. In fact, two additional key components of the new accreditation program will be composite quality scores centered on patient experience and long-term outcomes.

The previous paradigm and data auditing system was not sufficient to prove the need for support groups or integrated health personnel and, to some extent, this goal has proved elusive. The government, employers, insurance companies, and patients (who are the ultimate payors) are asking important questions about who should get which procedure, what the long-term outcomes should be, and how they can best be obtained. They are also keenly aware of the outcomes of patient experience surveys, increasingly requiring this feedback.
In regards to outcomes-based accreditation, it is the role of the integrated health team to own these additive quality domains that measure the effectiveness achieved by MBS, the long-term care of the patient, and the improvement of the patient experience and educational process.

The other part of the new program in which integrated health team members will be essential is the collaborative effort at continuous quality improvement. In this area, the integrated health bariatric coordinators and mid-level providers can take a key role in helping to define the projects at the local and regional collaborative level and working to provide that leadership. At the end of the day, the collaborative effort to improve safety and effectiveness is critical to improving our care and takes place in the operating room, in the clinic, and at the bedside on a local level. Quality, like politics, is a local issue.

Over the next few months, there will be an opportunity for all members to comment on the newly defined standards for accreditation in the outcomes-based model before it is finalized. I hope each person will take advantage of this opportunity to contribute his or her comments to the unified MBS accreditation standards.

Why NOT Excellence? The importance of a name in determining content. When the ASBMS BSCOE program began, the word excellence was used to describe the programs and surgeons involved. Many outside, third parties jumped on that bandwagon and “Center of Excellence,” in a number of areas of medicine, have sprung up. These COEs are sometimes sponsored by companies more interested in profit than in patient safety or quality. At many levels, especially as surgeons, the word excellence has great appeal. According to the definition listed on Wikipedia, excellence is a talent or quality which is unusually good and so surpasses ordinary standards. It is also an aimed for standard of performance.

Inherent in the definition is the ability to measure the quality or talent in such a way that is fair and unbiased. How many times have you heard a surgeon say “my outcomes would look great if the sickness of my patients were taken into account.” However, the measurement of risk-adjusted outcomes has proven elusive, requiring rigorous and complete data at time points remote from the surgical event, thus making it very difficult to collect. The use of the word excellence also has implications of a promise and that is where it becomes a legal liability. The original ASMBS program sought to convey quality by saying that surgeons who did at least 50 cases per year and programs that performed 125 cases per year were “excellent,” however outcomes were never measured. Programs that did not have outcomes that “surpassed” ordinary standards were part of the ASMBS BSCOE network. Payors comparing claims data to accreditation were becoming aware of this fact and some like Blue Cross Blue Shield (BCBS) of Michigan dropped the requirement for accreditation by ASMBS from their requirements for MBS. The handwriting was on the wall. The claim of excellence can also result in increased risk for liability because of the implied promise of excellence translates in many payors and patients minds as “risk free” or “adverse event free” surgery. A recent case in Florida that was returned with a large verdict for the plaintive is an example of this issue.
The second problem with the use of the word excellence is that it establishes a very competitive environment. The “I am excellent and you are not” mentality does not contribute to a team approach and patient safety. As increasing numbers of cases are being performed around the country, we become more aware that we are actually all in this together. Rather than a competitive environment promoted by “excellence,” we need to foster communication and collaboration between programs, surgeons, and integrated health teams. Sharing best practice will lead to a safer environment that will promote increased access (by payors) and increased feeling of safety (by patients).

As the ASMBS moves into the new paradigm of outcomes-based accreditation and quality improvement, we have decided against using the word excellence in favor of achieving best practice in patient safety for all. In particular, we intend to embrace the new program with an established MBS surgeon or new fellow and help them achieve enhanced patient safety from their initial experience and monitor and provide materials to make their first cases in a new facility as safe as possible. This collaborative, supportive approach will inevitably increase our collegiality and ability to solve local and regional access to care problems together.

International Membership and Global Healthcare
The international community has embraced the new approach of ASMBS and ACS to outcomes-based accreditation and the potential expansion of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program to promote one standard in MBS global healthcare. Many international members are very interested in working with the ASMBS and ACS to extend the accreditation program and data registry by working with the national societies of each country. Both the ASMBS and ACS enjoy strong international membership committed to provide extraordinary patient care. The extension of accreditation to our international colleague’s worldwide will help us to realize the goals of a Metabolic and Bariatric Surgery Global Healthcare Quality Network. As the new accreditation standards are established and brought online in early 2013, we expect to begin working with interested international surgeons/societies to establish this new global network of safety in MBS.
Drs. Robin Blackstone, Jaime Ponce, and Raul Rosenthal will be hosting a dinner for all International Society Presidents on Saturday evening, June 16, 2012, prior to the beginning of the ASMBS Annual Meeting in San Diego, California to discuss the future of the network. A presentation by Dr. Blackstone will be part of the meeting.

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Category: ASMBS News and Update, Past Articles