Raising the Standards with MBSAQIP: Part 7

| February 1, 2023

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 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 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 current 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 and Des Moines, Iowa, and Clinical Associate Professor at University of Iowa. Dr. Peterson is current Co-chair of the MBSAQIP Standards/Verification Subcommittee, MBSAQIP Site Reviewer; 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. 2023;20(2):22–23.

The following article is the seventh and final article 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 7 and 8.

Standard 7: Quality Improvement

Standards 7.1: Adverse Event Monitoring. Patient safety and adverse event monitoring must be implemented by all MBSAQIP-accredited centers through the Metabolic and Bariatric Surgery (MBS) Committee and led by the MBS Director. Examples of adverse events include, but are not limited to, complications, readmissions, reoperations, prolonged length of stay, postoperative morbidity, unplanned admission to the intensive care unit (ICU), and mortality. A policy must be in place to review all adverse events, and meeting minutes must show that the adverse events were reviewed. 

Only one change was made for Standard 7.1 and refers to the language for mortality review. The language referring to “in-hospital” mortality review was confusing and frequently misinterpreted. Therefore, this language was removed and changed to indicate that all mortality occurring within the first 90 days postoperatively must be reviewed. 

A frequently asked question received by MBSAQIP about this standard is listed below. 

Q: Must we review all mortality cases occurring within 90 days of MBS or only those where the cause of death was related to the metabolic and bariatric procedure?

A: All 90-day mortality cases must be reviewed by the MBS Committee within 60 days of discovering the patient’s death, regardless of whether mortality was related or unrelated to the metabolic and bariatric procedure. There are no mitigating circumstances or exclusionary criteria that override this requirement. 

Standard 7.2: Quality Improvement Initiatives. Quality improvement (QI) emphasizes a continuous, multidisciplinary effort to improve the process of care and its outcome. All QI initiatives must be based on an existing problem identified by a reliable data source that consistently obtains valid and objective information necessary to identify opportunities for improvement at the center. The semiannual risk-adjusted reports (SARs), non-risk-adjusted reports, and other data sources (e.g., patient experience scores) are valuable tools to evaluate areas for improvement for the center and must be used to identify pertinent QI initiatives. These initiatives must change structure, processes, and/or clinical pathways within the center. Information about QI, including a detailed review of this six-step process, can be found on the MBSAQIP website (https://www.facs.org/quality-programs/mbsaqip/resources).

There was no major change in the language for Standard 7.2. The updated language more strongly emphasizes the existing requirement of properly structured, data-driven QI initiatives. 

It is essential that a QI project be initiated for high outlier metrics listed in the SAR. If the center is a high outlier in more than one metric on the SAR, the MBS Committee must prioritize these clinical issues, and the next QI initiative must address the issue associated with the greatest risk to patient safety. Although only one QI initiative is required each year, the MBSAQIP encourages initiating more than one QI project.

Standard 7.3: Annual Compliance Reports. There was no major change in the language for Standard 7.3. The MBS Director and MBS Coordinator are required to submit an Annual Compliance Report (ACR) to the MBSAQIP in the second and third years of the triennial reaccreditation cycle.

A frequently asked question received by MBSAQIP about this standard is listed below.

Q: Can we contact MBSAQIP to request copies of previously submitted ACRs?  

A: No. Records of all submitted ACRs must be kept by the accredited center, just like all other documentation required for Standards compliance. 

ACRs are now required to be uploaded to the MBSAQIP Quality Portal. Previous ACRs that your center has uploaded to the Quality Portal can be accessed there for future reference, but ACRs submitted prior to 2020 are not likely to be available through the Quality Portal.

Standard 8: Professional and Community Outreach 

Standard 8.1: Support Groups. MBSAQIP-accredited centers must provide regularly scheduled, organized, and supervised support groups for metabolic and bariatric patients. Regularly scheduled support groups must be made available a minimum of every two months and can be in-person, web-based, or teleconferenced. The surgical practice(s) and/or center are allowed to organize support groups, but the entity responsible for administering each support group must be clearly identified. A licensed healthcare provider must be present to supervise all support groups. The center’s MBS Committee must determine the required credentials for healthcare providers supervising support groups. The center must provide patients with information regarding all of their options for support groups. 

All support group activities must be documented, including group location, meeting time, supervisor, curriculum, and number of people in attendance. Other activities, including online forums, exercise instruction, and clothing sales must be noted, but do not require full documentation. 

There was no major change in the language for Standard 8. Frequently asked questions received by MBSAQIP about this standard are listed below.

Q: Do support groups need to be run by the hospital, or can they be offered by the surgeon’s practice?  

A: Either is acceptable if they meet compliance, as outlined in Standard 8.1. 

Q: Can support groups be pre-recorded?   

A: No. Support groups must be live, interactive events. They cannot be pre-recorded.

Q: Can support groups be held virtually?    

A: Yes.

This concludes the seventh article of Raising the Standards with MBSAQIP. The Optimal Resources for Metabolic and Bariatric Surgery outlines the requirements for facilities to follow when seeking and maintaining accreditation. MBSAQIP Accreditation provides guidance for facilities aspiring to build the structure and outcomes expertise necessary to provide safe, efficacious, and high-quality care to all metabolic and bariatric patients. There are currently more than 900 MBSAQIP-accredited centers in the United States and Canada, with multiple international centers participating as Data Collection Centers. More than 200,000 bariatric cases are captured annually in the MBSAQIP Registry.   

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Category: Past Articles, Raising the Standard

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