Raising the Standard: Raising the Standards with MBSAQIP: Part 5

| December 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; 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-Elect 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(12):20–21.

The following article is the fifth part of a series discussing the revised version of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) standards that officially became effective October 1, 2022. The article will review Standards 4.5 to 4.15 and Standard 5. The remaining MBSAQIP standards will be reviewed in future articles.

Standard 4: Personnel and Services Resources

Standards 4.5–4.14: Personnel and Service Resources. There were no major changes in the language for Standards 4.5 to 4.14. However, frequently asked questions for these standards are listed below. 

Standard 4.5: Multidisciplinary Team. 

Q: Must we provide credentials, licensure, or certifications for every individual provider of the multidisciplinary team? 

A: No. The center only needs to provide qualified documentation for one person from each of the required disciplines listed in Standard 4.5. 

Standard 4.6: Advanced Cardiovascular Life Support (ACLS). 

Q: Must we provide credentials for every individual provider with ACLS qualifications?

A: No. The center only needs to provide documentation for one ACLS-qualified provider.

Standard 4.8: Critical Care Unit (CCU)/Intensive Care Unit (ICU) Services. 

Q: Must we provide credentials for every individual CCU/ICU nurse/physician? 

A: No. The center only needs to provide documentation for one ICU nurse and physician.  

Standard 4.9: Anesthesia Services. 

Q: Does our center need to have a bariatric-specific anesthesia protocol?   

A: Yes. The center must have an anesthesia protocol that specifically addresses all the elements outlined in Standard 4.9. The protocol must be specifically tailored to patients undergoing metabolic and bariatric surgery (MBS). 

A common deficiency encountered during site surveys include centers using generic anesthesia protocols that do not specifically address the care of MBS patients. The anesthesia pathway must be specific to the care of the MBS patient at the center. Ideally, the anesthesia pathway documents should contain institutional letterhead and indicate that it has been reviewed and approved by the MBS Committee. 

Standard 4.10: Endoscopy Services.

Q: Do diagnostic endoscopists need to be part of the MBS Committee? 

 A: No. Only endoscopy providers performing weight loss procedures or the treatment of metabolic disease processes need to be members of the MBS Committee.

Q: Must endoscopy services be available 24/7/365?  

A: No. Endoscopy services do not always need to available, but they must be provided onsite for all facilities with a Comprehensive Center designation.   

Standard 4.11: Diagnostic and Interventional Radiology Services. 

Q: Must diagnostic and interventional radiology services be available 24/7/365?

A: No. Diagnostic and interventional radiology services do not always need to available, but they must be provided onsite for all facilities with a Comprehensive Center designation. 

Standard 4.15: Children’s Hospital Service Requirements. One important compliance change made in the revised standards is clarification of the definition of adolescence. Previously, the adolescent age was limited to patients 18 years of age and younger. Previous language was overly restrictive and implied that adolescent centers could not operate on patients over the age of 18 years, when that was never the intent. Continuity of care was being compromised for select patient populations that routinely follow-up long-term at children’s hospitals. Adolescent centers are now approved to operate on patients over the age of 18 years, but cases of patients over the age of 21 years need to be reviewed by the MBS Committee to determine if the patient should be maintained at the adolescent center for continuity of care or deferred to an accredited adult center. 

Standard 5: Patient Care: Expectations and Protocols

Standard 5.1: Patient Education Pathways. A significant compliance change was made to this standard, indicating that patient education pathways must be reviewed and revised annually by the MBS Committee with updated procedural volumes and outcomes data. Patient education pathways must have up-to-date information on case volume, procedure mix, outcomes data, and other relevant changes to properly address the informed consent process. 

The education pathway format can be developed per the center’s discretion, but it needs to list all procedures offered at the center, case volumes for those procedures, and adverse events. Regarding adverse events, major events, such as leaks, bleeds, and readmissions, should be listed. Additional patient education information can include, but is not limited to, expected weight loss, body mass index (BMI) change, comorbidity resolution, and lifetime numbers. Many centers are simply offering this information on their website to minimize the cost of updating print materials and videos

Frequently asked questions regarding the patient education pathways are listed below. 

Q: Our center has a patient pamphlet that does not cover all the required elements of the patient education pathway. Do we need additional education materials?

A: Yes. Advertising materials for your program are not the same as the patient education pathway required in Standard 5.1. The patient education pathway must include outcomes data, case volume, and additional information that must be discussed with the patient. This information must be revised and updated annually in your education materials. Having separate advertising materials for the program that provide a more basic, high-level overview of the bariatric surgery is perfectly acceptable, but those materials will not meet the measure of compliance for this standard by themselves. 

Standards 5.2 and 5.3: Patient Care Pathways and Written Transfer Agreements. There are no compliance changes for Standards 5.2 and 5.3, but there are two frequently asked questions to discuss. 

Standard 5.2 Patient Care Pathways.

Q: Is there a required template or format for our patient care pathways? 

A: No. Flow charts, tables, algorithms, patient care crosswalks, word documents, or any other format is acceptable. The only requirement is for the patient care pathway to address all necessary elements outlined in Standard 5.2.

Standard 5.3 Written Transfer Agreement.

Q: Our center manages all complications on-site. Do we need a transfer agreement?

A: No. If your center can manage the full complement of metabolic and bariatric complications onsite, you do not need a transfer agreement, and no documentation is required for this standard. Compliance with this standard will be confirmed during the site visit. 

This concludes the fifth article of Raising the Standards with MBSAQIP. The next article will review the Obesity Medicine Standards.  

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Category: Past Articles, Raising the Standard

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