Raising the Standard: Raising the Standards with MBSAQIP: Part 3

| September 1, 2022

by Wayne J. English, MD, FACS, FASMBS; David Provost, MD, FACS, FASMBS; Teresa LaMasters, MD, FACS, FASMBS; Richard Peterson, MD, MPH, FACS, FASMBS, DABS-FPMBS; Paul Jeffers, BS, BA; and Cassandra Peters, BA

Dr. English is a past Co-Chair of the MBSAQIP Standards/Verification Subcommittee and Associate Professor of Surgery at Vanderbilt University Medical Center in Nashville, Tennessee. Dr. Provost is a past Co-Chair of the MBSAQIP Standards/Verification Subcommittee and Professor of Surgery at Baylor Scott & White Medical Center – Temple in Temple, Texas. Dr. LaMasters is a Co-Chair of the MBSAQIP Standards/Verification Subcommittee, MBSAQIP Site Reviewer, President of the American Society for Metabolic and Bariatric Surgery, Medical Director at UnityPoint Clinic Weight Loss in Des Moines, Iowa, and Clinical Associate Professor at University of Iowa. Dr. Peterson is a Co-Chair of the MBSAQIP Standards/Verification Subcommittee, MBSAQIP Site Reviewer, and Co-clinical Editor of Bariatric Times; Professor of Surgery, UT Health San Antonio; Chief, Bariatric and Metabolic Surgery UT Health San Antonio in San Antonio, Texas. Mr. Jeffers was the MBSAQIP Verification Specialist from July 2015 to April 2022 and is currently the Commission on Cancer Standards Development Manager. Ms. Peters is the MBSAQIP Program Specialist, Area of Continuous Quality Improvement, Division of Research and Optimal Patient Care for the American College of Surgeons.

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2022;19(9):16–17.

The following article is the third of a series of articles discussing the upcoming revised version of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) standards. The revised standards will go into effect October 2022, at which time the MBSAQIP will begin verifying compliance with the updated standards. The article will review the Metabolic and Bariatric Surgery (MBS) Committee, Director, Coordinator, and Clinical Reviewer within Standard 2. The remaining MBSAQIP standards will be reviewed in future articles.

Standard 2: Program Scope and Governance

Standard 2.4: MBS Committee. The control of the MBS center resides with the MBS Committee and should involve, at a minimum, a surgeon director, all surgeons performing MBS at the center, a coordinator, a clinical reviewer, and institutional administration representatives involved in the care of MBS patients. All participants of the committee should provide input toward the final decisions in developing the structure, process, and improvement plans for the MBS center. Other members of the MBS Committee can include, but are not limited to, charge nurses for dedicated patient areas and personnel that can provide information on services provided with patient transportation, central supply, radiology, and equipment purchasing. 

For the 2019 Standards–Revised, the language of this standard was strengthened around nonsurgeon proceduralists and their required involvement with the MBS Committee. Additionally, two compliance changes were made, which involves the patient education pathway (Standard 5.1) and adolescent centers. Patient education materials must be reviewed and revised annually by the MBS Committee to provide up-to-date information on case volume, procedure mix, outcomes data, and other relevant changes. The second change applies to adolescent centers only. The MBSAQIP recognizes that under certain circumstances, patients older than 18 years of age may undergo metabolic and bariatric treatment at an accredited Adolescent Center. It is now required that patients over 21 years of age need to be reviewed by the MBS Committee to determine if continuity of care should be maintained or deferred to an accredited adult inpatient facility.

Frequently asked questions regarding the MBS Committee are listed here. 

Q: We are an Initial Center. Must our MBS Committee meet three times and have the annual comprehensive review meeting prior to applying for accreditation and/or our first site visit? 

A: No. The MBS Committee must be established and meet at least once prior to application for accreditation. That meeting must address important standards compliance requirements and ensure the center is prepared to move forward with seeking MBSAQIP accreditation. The meeting minutes must be documented as required by Standard 2.4.

Q: Are virtual or teleconferenced meetings of the MBS Committee permissible? 

A: Yes. The MBS Committee may convene in any manner conducive to hosting a productive meeting. The meeting minutes must still be taken in accordance with Standard 2.4, and all attendees who would normally attend must be present. A hybrid meeting is also acceptable (mix of in-person and virtual attendees).

Q: Are nonsurgeon proceduralists required to participate in the MBS Committee? 

A: Yes. Endoscopists and other proceduralists performing endoluminal procedures for the treatment of obesity or metabolic disease processes must be members of the MBS Committee and function in the MBS Committee in the same capacity as metabolic and bariatric surgeons, including participation in discussions regarding their specific patients and the review of any adverse events resulting from procedures they have performed for the treatment of obesity and metabolic diseases. This includes proceduralists performing revisional bariatric procedures, such as transoral outlet reduction (TORe) to address gastrojejunal anastomosis dilation. Endoscopists exclusively performing esophagogastroduodenoscopies (EGDs) and similar procedures for diagnostic purposes are not required to be a part of the MBS Committee, unless otherwise requested by the MBS Director or MBS Committee. 

Q: Are general surgeons covering bariatric call required to participate in the MBS Committee? 

A: No. They are welcome to attend and participate, but they are not required to do so, unless their presence is specifically requested by the MBS Director or MBS Committee.

Standards 2.5, 2.6, and 2.7: Medical Director, Coordinator, and Clinical Reviewer. There are no changes to these standards, except that the center is required to terminate access for any personnel who are no longer authorized to access the MBSAQIP registry using the data platform contacts management page in the quality portal.

One common site survey deficiency encountered relates to the MBS Clinical Reviewer’s inability to enter all required data in a timely manner and accessing office records from surgeons performing MBS at the center. The surgeon’s office staff cannot simply provide summary data to the MBS Clinical Reviewer. The MBS Clinical Reviewer must have unbiased access to all records. 

Frequently asked questions to MBSAQIP staff are listed here. 

Q: Is it permissible for our center to have co-MBS Directors?

A: No. A single individual must fill the position of MBS Director.

Q: Our MBS Director is retiring or otherwise leaving our center. What should we do? 

A: All changes in the MBS Director position must be reported to MBSAQIP within 30 days. A new MBS Director must be appointed within 12 months of the previous Director’s departure. The MBSASQIP Accreditation Team will provide additional guidance based around your center’s specific circumstances. 

Q: The MBS Director, Coordinator, or Clinical Reviewer must be fully integrated into the institution’s organizational framework. What does this mean? 

A: The MBS Director, Coordinator, or Clinical Reviewer position must be incorporated into the institution’s chain of command (typically through an organizational chart), clearly documenting the MBS Director’s, Coordinator’s, or Clinical Reviewer’s authority to complete their prescribed duties as outlined in Standard 2.5, 2.6, or 2.7. An organizational chart is not specifically required if other documentation exists to support the position’s authority and integration. It must be clearly identified which bariatric team members report to the MBS Director, Coordinator, or Clinical Reviewer and to whom the MBS Coordinator or Clinical Reviewer reports within the institution. 

Q: What credentials are acceptable to prove that the MBS Coordinator is a licensed or registered healthcare professional? 

A: Acceptable credentials include, but are not limited to: registered nurse (RN), physician assistant (PA), nurse practitioner (NP), advanced practice nurse (APN), registered dietitian (RD), or licensed physical therapist or physical therapist assistant (PT/PTA).

Standard 2.8: Obesity Medical Director will be discussed in a future article involving obesity medicine services in Standards 5 and 6. 

This concludes the third article of Raising the Standards with MBSAQIP. The next article will review Standard 3 (Facilities and Equipment Resources).  

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Category: Past Articles, Raising the Standard

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