Raising the Standard: Preparing for Your Virtual Site Visit

| August 1, 2021 | 0 Comments

by Kellie Armstrong, MSN, RN, CBN; Anthony T. Petrick, MD, FACS, FASMBS; and Dominick Gadaleta, MD, FACS, FASMBS

Ms. Armstrong is Manager, Center for Bariatric Surgery at The Miriam Hospital in Providence, Rhode Island. Dr. Petrick is Chief Quality Officer, Geisinger Clinic; Director of Bariatric and Foregut Surgery, Geisinger Health System, Danville, Pennsylvania. Dr. Gadaleta is Chair, Department of Surgery, South Shore University Hospital; Director, Metabolic and Bariatric Surgery, North Shore and South Shore University Hospitals, Northwell Health, Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

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. 2021;18(8):18–19


“Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) works to advance safe, high-quality care for bariatric surgical patients through the accreditation of bariatric surgical centers. A bariatric surgical center achieves accreditation following a rigorous review process during which it proves that it can maintain certain physical resources, human resources, and standards of practice. All accredited centers report their outcomes to the MBSAQIP database.”1

-MBSAQIP website

As a result of the COVID-19 pandemic, all site visits and program reviews were suspended. As part of the return to normal, most accrediting agencies moved to virtual visits. Each organization was responsible for designing their own Health Insurance Portability and Accountability Act (HIPAA)-compliant structure. Joint commission, Committee on Trauma (COT), and MBSAQIP, for example, all designed different agendas and handled the facility tour differently. This column may serve as a guide to new and reaccrediting programs, based on the experience of one recently reaccredited program and one experienced site reviewer.

The Miriam Hospital Center for Bariatric Surgery has been accredited by MBSAQIP since 2011. In 2014 and 2017, they were certified as an MBSAQIP Comprehensive Center with Adolescents Qualifications. In 2020, they were up for renewal and were applying for accreditation for Obesity Medicine Qualifications. The in-person site visit was scheduled for April 2020 and was cancelled a week prior due to travel restrictions in place during the COVID-19 surge. Beginning in late fall 2020, the center’s metabolic and bariatric surgery (MBS) coordinator was out on a two-month leave of absence, returning to work on January 4, 2021. Two weeks later, the MBS director announced he was resigning as director for another position in a different state. He also informed the center that he had asked MBSAQIP to fast track the site visit so it would be done before his departure in April 2021. The site visit was then scheduled for March 3, 2021, a mere six weeks later. What follows are recommendations from that site visit, as well as an independent reviewer’s recommendations.

Practice, Prep, Send out invites for the day and sessions: PRACTICE Again!

First you need to pick a platform. Use programs with which you’re familiar! Miriam used Microsoft Teams as the platform for the virtual visit because it was the platform already in use at the center. Practice, practice, practice. Take the time to practice sharing files and videos and connecting team members, both within your facility and with outside sites and devices. Practice several times as a team. Then, practice with the team and the site reviewer from MBSAQIP. Then practice again as a team. Practice signing on, practice running the PowerPoint presentations, running the videos, sharing your electronic medical record (EMR), and switching from office to hospital to radiology platforms or files saved on your network. Make it so that people have the ability to sign on from different locations on different kinds of devices as well.

Discuss the agenda with your site reviewer, and recognize time will be needed for breaks. These can be planned or as needed. One of the advantages of the pre-visit practice session is having more contact with the site reviewer. Use that to your advantage, listen to the site reviewer’s suggestions and preferences, and ask questions you might have regarding the visit. Be sure to fill out the MSAQIP Site Visit Complication List, and include enough information in the Complications Detail tab as needed to give the site reviewer a good sense of the timeline. Above all else, please ensure the Complications List is completed in a HIPAA-compliant manner.

Other recommendations include sending out an all-day Microsoft Teams (or other video chat platform, such as Zoom) invite to everyone who is being asked to participate. Then, send out specific and individualized invites to team members for the sessions where their participation is expected.

Below are suggestions for when the day finally arrives.

Welcome (7:45–8 AM)

Be on time and be ready, and open the session 10 to 15 minutes early. Let hospital leadership set the stage. Miriam began with a welcome from the president of their healthcare system, then the president of the hospital, followed by the medical director, who gave a PowerPoint presentation of the history of The Miriam Hospital and the bariatric surgery program. You know what information you want to convey to the site reviewer about your hospital, health system and program, so now is the time to do so. Invite the core group to the welcome, and remember it is important to end on time. 

Chart Review (8–11 AM)

Many programs are partly hospital based and partly based in the surgeon’s office. If the inpatient and outpatient EMR systems don’t “speak” to each other, it is beneficial to come up with a plan to merge them either electronically or scanned in on paper for ease of access. Be sure to scan each document separately and name them in an organized manner that makes sense to you.

Also, if you create a summary page for each case, and you plan to share with the site reviewer prior to the visit, it needs to be HIPAA compliant.

By providing the site reviewer a HIPAA-compliant summary of each case, the time needed to review is greatly reduced, and the allotted time is more than adequate. Miriam had all of their bariatric surgeons who had cases to be reviewed present, and they spoke about their individual cases as they were presented. Keep in mind, although not specifically addressed by MBSAQIP, having all of the surgeons present for the chart review may impact the site reviewer’s impression of the process improvement (PI) program in place and/or the role of the MBS director at the center. If you are thinking of having each surgeon present their own cases, you should discuss this with the site reviewer before the site visit.

Finally, allowing the site reviewer to control your screen once the chart is uploaded might improve the flow of the individual chart review. Letting the site reviewer navigate the screen and scroll through the documents at their leisure tends to create a more productive atmosphere. 

Facility Based Standards Compliance (11–11:30 AM) 

Formally known as facility tour. During the facility tour, Miriam used a PowerPoint presentation to show videos and pictures of their facility, starting from the main lobby, then moving to admitting; preoperative holding; operating rooms (OR); post anesthesia care unit; nursing units; emergency, radiology and endoscopy departments; and dietary offices. They also included a video related to the typical patient positioning in the OR. The staff from the different units/departments spoke to the environment of care for their units/departments while the presentation was being viewed live. 

Multidisciplinary Care Meeting (11:30–12:30 PM) 

Formally known as lunch. This is a meeting with the center’s extended bariatric team and the site reviewer. The multidisciplinary care meeting will be led by the site reviewer, who will do the following: 

  • Address questions or areas for clarification from the chart review 
  • Address questions or areas for clarification from the center’s Pre-Review Questionnaire (PRQ) 
  • Discuss the center’s quality improvement (QI) initiatives and methodology for execution 
  • Address questions or concerns from the center and team members2

Miriam had a list of “best practices.” The staff and managers of the different units/departments created the list by deciding what they considered to be best practices in their units/departments. During the facility tour and multidisciplinary meeting, the staff spoke about their “best practices.” Additionally, the annual quality projects should be presented at this time to highlight the center’s focus since the last review.

One-on-one Interviews (12:30–1 PM)

The most important part of this half hour is to ensure the interviews are confidential and the next person is readily available, but not listening in on the conversation. As a site reviewer, Dr. Dominick Gadaleta prefers to end with the MBS coordinator who is required for the next session, but there is no set order; of course, the length of each individual interview (6–10 minutes) will vary depending on the level of accreditation being sought, i.e., the number of required interviews. 

Pathway and Protocols Review (1–2 PM)

This is the time to review your pathways and protocols. Keep in mind, although many of the documents were previously uploaded to the portal and available for review prior to the site visit, you should be prepared to show them again. Like the chart review, electronic organization and preparation is essential to smoothly going from standard to standard and assuring the site reviewer is able to review all of the documents in addition to those highlighted in red on the agenda.

Site Reviewer Preparation (2–2:30 PM)

During this time, the site reviewer will summarize notes and prepare findings for the exit interview. Miriam kept the Microsoft Teams link live and asked everyone to leave the Teams meeting and conference room until the assigned time for the exit interview. 

Exit Interview (2:30 PM)

For the exit interview, invite everyone who participated in the day to join and be a part of the wrap up. The site reviewer will read a brief pre-prepared statement on behalf of the MBSAQIP and present the findings from the site visit, including an overview of the day’s events and key discussion topics. The site reviewer will highlight the center’s performance relative to the following areas: 

  • Strengths 
  • Opportunities for improvement 
  • Standards noncompliance 

The site reviewer will also present their accreditation recommendation and will address any final questions from the center’s staff.2 The site visit will conclude at the end of the exit interview.

In the end, The Miriam Hospital Center for Bariatric Surgery was reaccredited as an MBSAQIP Comprehensive Center with Adolescent and Obesity Medicine Qualifications. The site reviewer “found no deficiencies and that it was an exemplary program.” The chief of surgery of the healthcare system, president of the hospital, chief medical officer, and bariatric medical director each gave a brief closing statement and thanked the MBSAQIP Staff, the site reviewer, the bariatric team, and the hospital and surgeon’s office staff that are involved with the care of their patients for a wonderful productive day.

References

  1. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.American College of Surgeons. https://www.facs.org/quality-programs/mbsaqip. Accessed July 20, 2021.
  2. MBSAQIP Site Visit Agenda. https://accreditation.facs.org/accreditationdocuments/MBSAQIP/SiteVisit/MBSAQIP-Site-Visit-Agenda-100119.pdf. Accessed July 20, 2021.   

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Category: Past Articles, Raising the Standard

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