Raising the Standard: Raising the Standards with MBSAQIP: Part 4

| November 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 Co-Chair of the MBSAQIP Standards/Verification Subcommittee and Associate Professor of Surgery at Vanderbilt University Medical Center in Nashville, Tennessee. Dr. Provost is 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 member 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 and Des Moines, Iowa, and Clinical Associate Professor at University of Iowa. Dr. Peterson is 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(11):18–19.

The following article is the fourth of a series of articles discussing the upcoming revised version of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) standards effective October 1, 2022. The article will review Standard 3 and Standards 4.1 to 4.4. The remaining MBSAQIP standards will be reviewed in future articles.

Standard 3: Facilities and Equipment Resources

Standards 3.1, 3.2, and 3.3: Health Care Facility Accreditation; Facilities, Equipment, and Furniture; and Designated Bariatric Unit. There were no major changes in the language for Standard 3. However, frequently asked questions regarding Standard 3 are listed below. 

Q: Can we provide bariatric commodes instead of appropriately weight-rated toilets? 

A: No. Bedside commodes can be provided in addition to appropriately weight-rated toilets, but cannot be used as a substitute for appropriately supported toilets.

Q: Does MBSAQIP require specific physical dimensions for hallways, doors, patient rooms, or other areas of the facility?  

A: No. The MBSAQIP Standards must accommodate the highest acuity patients with obesity and all prospective medical centers that may wish to apply for accreditation. Requiring minimum physical dimensions for specific areas of the medical facility would be unduly prejudicial against smaller medical facilities that only provide care for lower acuity patients.

Q: Standard 3.2 requires a care pathway for patients that exceed our center’s current equipment weight limits. What should this pathway entail? 

A: This pathway must address how care is delivered or deferred for patients who cannot be accommodated with your center’s current equipment. This can include referral to a nonsurgical obesity medicine program, preoperative patient optimization and weight loss, or referral of care to another medical facility that has the necessary equipment to safely provide care to patients who exceed the weight limits of your center’s existing equipment. 

Q: Can the designated bariatric unit move based on hospital census or other facility needs?  

A: Yes. The designated bariatric unit is required to ensure that appropriate care is provided by experienced nursing staff and advanced practice providers. If the staff caring for metabolic and bariatric surgery (MBS) patients is experienced in treating patients with obesity, the designated unit may be relocated.

Standard 4.1: Credentialing Guidelines for Metabolic and Bariatric Surgeons. The introductory paragraph for this standard was rewritten to emphasize that the center must have separate and distinct MBS credentialing requirements based on what is outlined in the standard.  

A common site survey deficiency encountered relates to the credentialing guidelines not being updated to reflect the current operative environment at the center. For example, a specific number of open procedures might be required for renewing privileges that is unachievable in the laparoscopic era of bariatric surgery. Centers might have started performing biliopancreatic diversion/duodenal switch or single anastomosis duodenoileostomy with sleeve gastrectomy, and this is not reflected in the center’s credentialing guidelines. Additionally, centers performing robotic procedures might not have separate robotic bariatric surgery credentialing criteria. 

A frequently asked question for Standard 4.1 is listed below.

Q: What is the difference between credential guidelines and credentialing requirements? 

A: The guidelines outlined in Standard 4.1 must be followed to create your center’s credentialing requirements for metabolic and bariatric surgeons and/or proceduralists. The guidelines presented in Standard 4.1 are just that—guidelines to help your center address the necessary elements that must be considered by your hospital’s credentialing committee when determining whether to grant MBS privileges to applicant physicians. The outlined list of guidelines in Standard 4.1 do not constitute credentialing requirements by themselves; they are specific elements that need to be addressed in your medical facility’s credentialing requirements for MBS. These requirements need to be specifically tailored to your medical facility in accordance with institutional policy. MBS credentialing requirements must also be separate and distinct from general surgery credentialing requirements.  

Standards 4.2 and 4.3: MBSAQIP Surgeon Verification and Metabolic and Bariatric Surgery Call Schedule. There are no changes in the language regarding Standards 4.2 and 4.3. However, there are some frequently asked questions and site survey deficiencies to discuss. 

Q: Do all metabolic and bariatric surgeons at our center need to be verified surgeons? 

A: No. Only the MBS Director is required to be a verified surgeon. Other surgeons are welcome to seek surgeon verification if they meet all the required criteria. 

Q: Does the verified surgeon annual volume requirement have to be performed at the center seeking MBSAQIP accreditation? 

A: No. Cases performed at other MBSAQIP-accredited centers can count toward the volume requirement to be a verified surgeon.

Q: Do we need to submit surgical privileges for all surgeons covering call?  

A: Yes. Your center must provide privileges for all metabolic and bariatric surgeons and all general surgeons covering call.

Q: What is the minimal training required for general surgeons covering bariatric surgery call? 

A: 1) Metabolic and bariatric procedures commonly performed at the center; 2) Signs and symptoms of postoperative complications; and 3) Management and care of patients by a review of the center’s clinical pathways and protocols.

Q: Do general surgeons covering call need to have bariatric-specific continuing medical education (CME)?   

A: No. Any additional training requirements for general surgeons covering call, such as bariatric-specific CME, beyond the requirements outlined in Standard 4.3, are at the discretion of the MBS Director and the MBS Committee.

Many centers provide a generic general surgery call schedule without any title. This is considered a minor deficiency that will require correction. Ideally, the document provided for site survey should be titled as the bariatric surgery call schedule, preferably on a document with institutional letterhead.

Standard 4.4: Staff Training. Revisions to Standard 4.4 clarify the expected documentation that must be provided for the site survey and include the addition of both course materials and records of completed training to the documentation section. 

Frequently asked questions for Standard 4.4 are listed below.

Q: Do the requirements for staff training apply to our bariatric surgeons? 

A: Yes. Metabolic and bariatric surgeons and general surgeons covering bariatric call are required to complete all three training levels outlined in Standard 4.4.

Q: For compliance with Standard 4.4, does our center need to provide the training materials for the different levels of training or the records of staff training completion? 

A: Both. As outlined in Standard 4.4, accredited centers must provide both the course materials for each training level and records of training completion for relevant staff.

This concludes the fourth article of Raising the Standards with MBSAQIP. The next article will review Standards 4.5 to 4.12 (Personnel and Service Resources), and Standard 5 (Patient Care: Expectations and Protocols).  

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Category: Past Articles, Raising the Standard

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