mbsaqip virtual site visit agenda

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The American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) combined their respective national bariatric surgery accreditation programs into a single unified program to achieve one national accreditation standard for bariatric surgery centers, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

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. For information regarding MBSAQIP, please visit https://www.facs.org/quality-programs/mbsaqip .

About the MBSAQIP

The program accredits bariatric surgery centers in the United States and Canada that have undergone an independent, voluntary, and rigorous peer evaluation in accordance with nationally recognized bariatric surgical standards. Bariatric surgery accreditation not only promotes uniform standard benchmarks, but also supports continuous quality improvement. In the United States, more than 11 million people suffer from severe obesity and an estimated 93 million people have obesity. The comorbidities associated with obesity range from diabetes and heart disease to certain types of cancers. Bariatric surgical procedures have been shown to reduce obesity, improve mortality, and decrease the health risks from chronic diseases such as cardiomyopathy and diabetes. For these reasons, the MBSAQIP will recognize those facilities that implement defined standards of care, document their outcomes, and participate in regular reviews to evaluate their bariatric surgical programs. – See more at: https://www.facs.org/quality-programs/mbsaqip

The American College of Surgeons (ACS) was founded in 1913 with the goal of improving surgical care and setting standards, and the current Joint Commission (JCAHO) grew out of the ACS Hospital Standards Committee in 1951. The ACS has been accrediting trauma programs through the Trauma Verification Program since 1987 and cancer programs through the Commission on Cancer since 1930. In 2005, in response to a growing need in the bariatric surgery community, the ACS released the first Bariatric Surgery Center Network (ACS BSCN) accreditation standards manual.

The American Society for Metabolic and Bariatric Surgery (ASMBS), founded in 1983, was formed to advance the art and science of metabolic and bariatric surgery by continually improving the quality and safety of care and treatment of people with obesity and related diseases through educational and support programs for surgeons and integrated health professionals. The leadership of the ASMBS found it within their mission to release their own set of accreditation standards for Bariatric Surgery Centers of Excellence (BSCOE) in 2004, creating two separate but similar accrediting bodies for bariatric surgery.

Both programs focused on three key principles: the leadership of surgeons, the necessity for a multidisciplinary team, and the reporting of outcomes to a national registry. Accreditation was based on procedure volume, as well as other structural and process measures that provided a framework for facilities performing these types of procedures. Even discounting the impact of the introduction of laparoscopy (a change from 2.1 percent in 1998 to more than 90 percent in 2008) and inclusion in the data of the adjustable gastric band (less 30 day mortality and morbidity), the adoption of accreditation standards led to a remarkable decrease in mortality from one in 200 patients to one in 1,750 patients. The incremental improvement in safety was facilitated by the adoption of laparoscopy and inclusion of the adjustable gastric band, which has a strong safety profile at 30 days, but recent study also shows a direct result of the implementation of the programs themselves, especially in higher-risk patients. The majority of centers offering bariatric surgery programs in the United States participated in one of the two accreditation programs. Major payers endorsed the performance of metabolic and bariatric surgery within one of these centers. The data registries for both programs were under development in 2006 and in 2011 had more than 100,000 patients per year being entered into one of the two registries.

In order to transition to the MBSAQIP, in March of 2012, the ACS signed a memorandum of understanding with the American Society for Metabolic and Bariatric Surgery (ASMBS) to unify their respective bariatric surgery center accreditation programs. As of April of 2012,, all institutions that met the standards under the two separate programs—the ACS Bariatric Surgery Center Network (ACS BSCN) program and the ASMBS Bariatric Centers of Excellence (ASMBS BSCOE) program—were extended accreditation in the joint Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). The new, joint program is administered by the staff and committees of the ACS, and all centers now submit data to the existing ACS bariatric data registry.

More in this topic

Through the unification of the ACS BSCN and ASMBS BSCOE programs, a committee structure to support the MBSAQIP has been developed. The MBSAQIP committee structure consists of an overarching advisory committee and four subcommittees, residing and serving as official committees of the ACS. The Committee on Metabolic and Bariatric Surgery (CMBS) , the advisory committee, serves the purpose of advising leadership on opportunities for the joint program and offers recommendations regarding operational activities related to program transition, development, and implementation of the new unified program. Four subcommittees under the advisory committee help provide support the operations of the program:

  • Standards is responsible for the development of new joint accreditation standards.
  • Verification  validates and certifies that each individual center meets accreditation criteria.
  • Data Registry and Reporting oversees the data registry and provides input on analytical and reporting tools to support the needs of the joint program.
  • Quality is responsible for all activities and initiatives that involve performance improvement, collaborative work, and the sharing of best practices.
  • See more at: https://www.facs.org/quality-programs/mbsaqip/about/governance

MBSAQIP Updates/News and “Ask MBSAQIP” Webinar Recordings: https://www.facs.org/quality-programs/mbsaqip/news Visit this webinar to learn more on how to prepare for a successful MBSAQIP site.

Register for an upcoming “Ask MBSAQIP” Webinar: https://www.facs.org/quality-programs/mbsaqip/ask-mbsaqip

MBSAQIP Resources and FAQs: https://www.facs.org/quality-programs/mbsaqip/resources

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MBSAQIP Coordinators

Description.

In this interactive session, MBS Coordinators will have the opportunity to learn from one another and network with their peers. We go over the basics of the MBS Coordinator role and how to set your program up for success; discuss the virtual site visit process and best practices for preparing for one; how to show the value of your program to hospital leadership; and how to improve your team dynamic. MBS Coordinators will have the opportunity to hear about novel ideas for supporting patients, discuss ways of structuring and staffing a program, and learn ways other MBS Coordinators approach QI projects with their teams. Bring your business cards and be prepared to pick the brains of your peers.

Learning Objectives

By the end of this sessions, participants will be able to:

  • Understand the coordinator role and ways improve team dynamics.
  • Discuss options for implementing positive change in their program through improved patient pathways, novel ideas for patient support, and project management tools
  • Describe how to show the value of their program to hospital leadership.
  • Describe best practices for organizing documentation and preparing for a virtual site visit.
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Raising the Standards with MBSAQIP: Part 6

mbsaqip virtual site visit agenda

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(1):22–23.

T he following article is the sixth 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 Standard 6 and Obesity Medicine Services (Standards 2.8, 5.6, and 6.4). The remaining MBSAQIP standards (Standards 7 and 8) will be reviewed in the next and final article in the series.

Standard 6: Data Surveillance and Systems

Standard 6.1: Data Entry. There was no major change in the language for Standard 6.1. Every metabolic and bariatric procedure (open, laparoscopic, hand-assisted, robotic, or endoscopic) performed for the treatment of metabolic or obesity-related diseases must be entered into the MBSAQIP Registry, and a letter of attestation confirming 100-percent data entry into the MBSAQIP Registry must be signed and confirmed by the metabolic and bariatric surgery (MBS) Director and MBS Clinical Reviewer. A frequently asked question about Standard 6.1 is listed below.  

Q: Our MBS Clinical Reviewer position was vacated unexpectedly, and some cases were not entered into the MBSAQIP Registry. How should this be handled?

A: Your site must keep accurate records of all cases that were not abstracted into the registry and continue to follow those patients long-term. When a new MBS Clinical Reviewer is hired, those cases that are not past the 90-day lock date must be entered into the MBSAQIP Registry.

Any cases that are not abstracted into the registry must be followed long-term, with accurate records of any postoperative occurrences for case review at your center’s next accreditation site visit.

Standard 6.2: 30-day and Long-term Follow-up. There was no major change in the language for Standard 6.2. The center must document a protocol to follow the long-term progress of all their metabolic and bariatric patients, as well as documenting the contact attempts. The center may cease attempts to contact patients after the patient is lost to follow-up or a no-show for two consecutive follow-up timeframes.

Standard 6.3: Data Review. There was no major change in the language for Standard 6.3. All centers are required to monitor their data. Ongoing review of the semiannual risk-adjusted reports (SAR) and unadjusted outcomes data is critical for continuous quality improvement. A frequently asked question about Standard 6.3 is listed below.  

Q: We are an Initial Center/our center has not yet received an SAR. How do we demonstrate compliance with this Standard?  

A: Initial Centers and centers that have not yet received their first SAR are exempt from demonstrating compliance with this standard. Once an accredited center receives their first SAR, the center is required to be compliant with this standard.  

If the center does not receive an SAR because they did not maintain a complete 30-day follow-up rate of greater than or equal to 80 percent, the center will be found noncompliant with Standard 6.3.

Obesity Medicine Medical Director, Obesity Medicine Services, and Data Collection

Standard 2.8: Obesity Medicine Director, Standard 5.6: Obesity Medicine Services, and Standard 6.4: Data Collection. To enhance collaboration between obesity medicine physicians and metabolic and bariatric surgeons, a panel of prominent obesity medicine specialists was gathered in 2018 to help develop obesity medicine standards for the third version of the standards released in 2019. Obesity Medicine Qualifications are separate and distinct from surgical and procedural accreditation, and only MBSAQIP Comprehensive Centers and MBSAQIP Comprehensive Centers with Adolescent Qualifications are eligible to seek MBSAQIP Obesity Medicine Qualifications. Using care pathways developed by an Obesity Medicine Director (OMD), in conjunction with the MBS Committee, MBSAQIP-accredited centers with Obesity Medicine Qualifications must be able to provide comprehensive, multidisciplinary obesity medicine services. Care pathways must be reviewed annually by the OMD in conjunction with the MBS Committee.  

There were no major changes to the Obesity Medicine Services for the new 2019 Standards-Revised.  

Q: Can the OMD also be the MBS Director?  

A: Yes. If the individual in question fulfills all the requirements outlined in both Standard 2.5 (MBS Director) and 2.8 (OMD), the MBS Director and OMD roles can be performed by the same individual.

Q: What data elements are required to comply with the obesity medicine data collection?  

A: The following patient variables must be captured for data collection and outcomes monitoring for obesity medicine patients:  

  • Patient information (Name, ethnicity, demographic information, etc.)  
  • Height and weight at initial presentation  
  • Body mass index (BMI) at initial presentation  
  • Body fat percentage at initial presentation  
  • Comorbidities at initial presentation  
  • Weight percentage change over time  
  • BMI change over time  
  • Body fat percentage change over time  
  • Comorbidity changes over time  
  • Anti-obesity medications
  • Complications and side effects of obesity medicine treatment.  

Capturing additional variables related to patient health and satisfaction and obesity medicine treatment is encouraged, but not required, and is at the discretion of the center’s OMD.

All patients receiving nonprocedural obesity medicine treatment at MBSAQIP-accredited centers with Obesity Medicine Qualifications cannot be captured in the MBSAQIP Registry, and instead must be captured using an independent, local level data collection method.

This concludes the sixth article of Raising the Standards with MBSAQIP. The next and final article reviewing the changes made to the 2019 standards will review Standards 7 and 8.  

Tags: MBSAQIP Standards , raising the standard

Category : Past Articles , Raising the Standard

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mbsaqip virtual site visit agenda

  • create your manuals that are required during a site inspection for accreditation approval
  • revise your current manuals to meet the new standards
  • provide 2019 manual notebooks with tabs and required documentation templates to customize to your specific program
  • Onsite Audit: A BariMD Bariatric Specialist will come to your facility and perform a thorough mock site audit (up to 3 days) to identify standard deficits.  BariMD will provide an extensive report with a detailed action plan to include sound step-by-step applicable recommendations.  A pre and post onsite audit meeting is held via teleconference with the key program staff members. The pre-audit meeting provides details and sets expectations for the onsite assessment. Information about the onsite audit will be provided and the agenda will be reviewed. The post audit review, which takes places one to two weeks after the onsite audit, is a detailed report of the assessment findings with specific recommendations to optimize the organization's readiness for the "official" site inspection.  The audit assesses both the hospital and bariatric practice(s) and the surgeons to determine the program's compliance with the 2019 MBSAQIP standards.
  • Virtual Audit: A BariMD Bariatric Specialist will walk through your facility virtually to perform a thorough mock site audit to identify standard deficits.  BariMD will provide sound step-by-step applicable recommendations when reviewing your manuals with you. Our specialist will ask to share the documentation included in each of the standard manuals so BariMD can assist you to be in compliance.  A chart audit session will be included.
  • Retainer Support: We can also provide monthly telephonic consulting support to guide you with any areas of concern.  We will answer questions, support you one-on-one with the standards and any recommendations based on your specific program needs.

mbsaqip virtual site visit agenda

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Site Reviewer Training Course: MBSAQIP

Site reviewer training course: mbsaqip 2856, instructions.

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The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Site Reviewer Training course is intended to equip Site Reviewers with the tools and knowledge needed to evaluate sites' compliance with the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Program's standards.

The course includes nine modules:

  • Welcome to ACS: an introduction to ACS and the ACS Quality Programs
  • Overview of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program: an introduction to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
  • Site Reviewers and Site Visits: a comprehensive overview of the Reviewer role
  • Program Standards: an overview of the standard domains, their outcomes, and common deficiencies
  • Operations : a review of the nuts and bolts of how the Quality programs operate
  • The Quality Portal: a review of the Site Reviewer-specific elements in the Quality Portal (QPort)
  • Preparing for the Site Visit: an overview of scheduling and other pre-site visit responsibilities
  • Conducting the Site Visit: a detailed walk-through of each component of the site visit
  • Following Up Post-Site Visit: an overview of what to expect following a site visit

Target Audience

The Site Reviewer Training Course: MBSAQIP is intended for MBSAQIP Site Reviewers at the American College of Surgeons.

Course Objectives

Upon completion of the course, you should be able to:

  • Explain how the American College of Surgeons has been striving towards continuous quality improvement.
  • Explain how your Quality Program strives towards its mission.
  • Explain the role of effective Site Reviewers in the ACS Quality Programs.
  • Interpret the program's standards accurately and consistently.
  • Explain the operations of the site visit process, including required documentation, scheduling, and payment.
  • Identify the location of key information in the ACS Quality Portal.
  • Explain how to effectively prepare for a site visit.
  • Explain how to conduct an effective site visit.
  • Explain how to effectively complete the post-site visit documentation.
  • Explain how site visit outcomes are determined.

Required Hardware/Software

Compatible Browsers 

  • Windows: Microsoft Edge (latest version), Google Chrome (latest version), Firefox (latest version) 
  • Mac: Safari (latest version), Google Chrome (latest version), Firefox (latest version) 

Required Browser Settings 

  • Javascript: JavaScript must be enabled for published courses to work. 
  • Font Downloads: Font downloads must be enabled to see the  correct fonts and characters . 

Additional Software 

  • Adobe Acrobat Reader 
  • Microsoft Office® Excel and Word 

If you have any questions about this activity, please contact  [email protected] .  

For technical assistance, please contact  [email protected]

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  • $0.00 Qty: Add to cart

About this course

Faculty credentials.

Disclosure Information

In accordance with the ACCME Accreditation Criteria, the American College of Surgeons must ensure that anyone in a position to control the content of the educational activity (planners and speakers/authors/discussants/moderators) has disclosed all financial relationships with any commercial interest (termed by the ACCME as “ineligible companies”, defined below) held in the last 24 months (see below for definitions). Please note that first authors were required to collect and submit disclosure information on behalf all other authors/contributors, if applicable.

Ineligible company

The ACCME defines an “ineligible company” as any entity producing, marketing, re-selling, or distributing health care goods or services used on or consumed by patients. Providers of clinical services directly to patients are NOT included in this definition.

Financial Relationships

Relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.  Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected.

Conflict of Interest

Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of an ineligible company with which he/she has a financial relationship.

The ACCME also requires that ACS manage any reported conflict and eliminate the potential for bias during the educational activity.  Any conflicts noted below have been managed to our satisfaction. The disclosure information is intended to identify any commercial relationships and allow learners to form their own judgments. However, if you perceive a bias during the educational activity, please report it on the evaluation. 

Planning Committee / Editorial Committee 

Samantha McArdle (Nothing to disclose)

Colleen Fleming (Nothing to disclose)

Emily Hoffman (Nothing to disclose)

Karen Pollitt  (Nothing to disclose)

Erica McNamara  (Nothing to disclose)

Pete Vega  (Nothing to disclose)

Lauren Muskara  (Nothing to disclose)

Cassandra Peters  (Nothing to disclose)

Lisa Hale  (Nothing to disclose)

CME Accreditation

Continuing medical education credit information, accreditation.

The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 Credits™

The American College of Surgeons designates this enduring activity for a maximum of 3 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continuous Certification program.

Course Completion

ALL ATTENDEES MUST COMPLETE THE COURSE EVALUATION in order to claim a CME Certificate or a Certificate of Completion. The course evaluation will appear once you take and complete this course. The following requirements will need to be completed:

  • Review all course materials
  • Course evaluation

Participants may only claim a maximum of 3  AMA PRA Category 1 Credits ™ for this activity.

mbsaqip virtual site visit agenda

Schedule Overview

Interactive Schedule

Program Highlights

The 37th ASMBS Annual Meeting will feature sessions centered around this year’s theme – Putting the Patient First .

Surgeon Sessions:

Private practice: overcoming new challenges cme.

Game changers in 2021: 2020 has impacted so many practices in several ways. How can you protect, improve or jump start your practice in 2021 and the future? Join us for innovative insights and strategies for your practice. View more session details.

Diversity: How to Showcase Hidden Talent in the Organization CME/CEU

This course is designed for individuals who are interested in increasing diversity within their organization to create a positive work environment and improve outcomes. The impact of diversity on how an organization functions will be reviewed. Strategies to effectively utilize diversity factors, manage a diverse workforce, and navigate workplace barriers will be discussed. Efforts to retain individuals from diverse backgrounds and its impact on organizational excellence will be addressed. View more session details.

Telehealth and Reaching Patients CME

This course will describe several telehealth platforms and compare and contrast them, as well as the pros and cons of telehealth versus in-person visits. Panelists will discuss what lessons have been learned about telemedicine during the pandemic and predict what lies ahead for telehealth. View more session details.

ASMBS/OMA Multidisciplinary Team Approach to Patients with Obesity CME/CEU

This collaborative panel presentation will discuss the anti-bariatric surgery patient, the post-bariatric surgery patient with weight recidivism or insufficient weight loss, and the challenging psychological patient presenting for bariatric surgery evaluation. View more session details.

Integrated Health Sessions:

Mbsaqip coordinator course ceu.

In this session, MBS Coordinators (novice & experienced) will learn about the necessary steps in preparing for a MBSAQIP virtual site visit, the assistive elements that MBS Directors can provide in navigating your hospital’s resouces, QI project development, MBSAQIP tools to ensure program success, & the session will conclude with an interactive networking session between colleagues. View more session details.

Patient Education CEU

The purpose of this symposium is to focus on issues and trends that occur during bariatric surgical patient education preoperative and pre-hospital discharge practices. This symposium will address four main topics: patient educational content and how its determined, process considerations related to dose, delivery, and access methods, the measurement of knowledge and effect on patient outcomes, and the effects of COVID-19 on patient education practices. View more session details.

Virtual Support Groups: Maximizing Value to the Paitent CEU

Join panelists for a discussion about the challenges and benefits of running virtual and hybrid support groups. Attendees will learn strategies to incorporate culturally specific practices in the virtual support group and will learn about upcoming advanced training for bariatric support group leaders. View more session details.

Bariatric Nursing Course CEU

Presented by experienced nurses within the specialty of bariatric surgery, this course offers information and guidance for the basic and safe care of bariatric surgery patients within a Bariatric Surgery Program. Target audience will be Nurses who are new to the specialty or who have worked in the specialty of bariatric surgery for less than 2 years. View more session details.

View the Accreditation page for more information.

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Accreditation

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MBSAQIP works to advance safe, high-quality care for bariatric surgical patients through the accreditation of bariatric surgical centers.

The program accredits inpatient and outpatient bariatric surgery centers in the United States and Canada that have undergone an independent, voluntary, and rigorous peer evaluation in accordance with nationally recognized bariatric surgical standards. Bariatric surgery accreditation not only promotes uniform standard benchmarks, but also supports continuous quality improvement.

How to Apply

New centers can apply here. It’s required that all new centers submit an application before gaining access to the Pre-Review Questionnaire (PRQ).

Here is a brief overview of the accreditation process. 

Application

  • Review MBSAQIP Standards to determine eligibility and appropriate designation level for your center
  • Submit online application (available at mbsaqip.org)
  • Center pays annual participation fee and executes contracts

Pre-Review Questionnaire (PRQ)

  • Center must meet compliance measures for all applicable Standards
  • Center submits compete Pre-Review Questionnaire (PRQ) through the MBSAQIP Quality Portal
  • MBS Clinical Reviewer is registered for training
  • Center is assigned a surgeon Site Visit Reviewer and must complete a site visit within 6 months of PRQ submission
  • MBS Clinical Reviewer must successfully complete online training modules and begin data entry to MBSAQIP Registry prior to site visit
  • Center will be notified of accreditation decision and receive the Accreditation Report approximately 8-12 weeks after the site visit
  • Center’s accreditation is effective retroactive to the date of the site visit and remain accredited for a 3-year term
  • Center submits Annual Compliance Report (ACR) at the first and second anniversary of initial accreditation and submits renewal application at 3 years

Existing MBSAQIP Centers

MBSAQIP-Accredited Centers are required to submit a renewal PRQ every three years to maintain accreditation.

Here is a brief overview of the renewal process for reaccrediting centers:

  • Review MBSAQIP Standards to confirm ongoing eligibility and appropriate designation level for your center
  • Renewal notice sent to the center 6 months prior to accreditation end date
  • Center submits complete Pre-Review Questionnaire (PRQ) through the MBSAQIP Quality Portal
  • Center must meet all applicable Standards at the time of PRQ submission
  • Center is assigned a surgeon Site Visit Reviewer after PRQ submission and must complete a site visit within 30 days of accreditation anniversary date
  • If accredited, the center is renewed for a new 3-year term from the date of initial accreditation

International Data Collection Center Applicants

Participation as a Data Collection Center is now available to International Centers.

Please note: Participation as a MBSAQIP Data Collection Center is NOT available to centers within the United States and Canada.

Data Collection Centers can apply using the MBSAQIP Quality Portal. No additional materials beyond the application are required for centers that are only seeking Data Collection participation. The bariatric surgeon leader at your center (MBS Director) is required to view the MBSAQIP Data Collection Webinar prior to applying. All staff or hospital administrators who will be integral to the successful implementation of a Data Collection program are encouraged, although not required, to view the webinar as well.

Please note that registration is required so that attendance by your MBS Director can be verified by the MBSAQIP. The webinar is pre-recorded so you may view it at your convenience.

All MBSAQIP centers are encouraged to participate in Ask MBSAQIP , our monthly webinar series.

MBSAQIP Standards

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Review and reflection: mbsaqip january 2023 semiannual report (sar).

mbsaqip virtual site visit agenda

Accreditation

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The American College of Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) January 2023 Semiannual Report (SAR) Review and Reflection activity will give all MBSAQIP Verified Surgeons and MBS Directors the opportunity to collect continuing medical education (CME) credits for the review, reflection, and learning of the January 2023 SAR.

  • We are offering up to 4 CME credits for the review, reflection, and learning with the January 2023 SAR. 
  • All MBSAQIP sites are eligible for participation.
  • The credits will be available to MBSAQIP Verified Surgeons and MBS Directors only.

Course Outline

  • SAR Reflection
  • Course Evaluation
  • Certificate
  • Post Survey

Target Audience

  • MBSAQIP Verified Surgeons
  • MBS Directors

Learning Objectives

This activity is designed for MBSAQIP Verified Surgeons and MBS Directors. Upon completion of this course, you should be able to:

  • Compare risk-adjusted surgical occurrence rates of your hospital to other hospitals
  • Identify areas needing improvement (for example, specific procedure, specialty, occurrence)
  • Explain your hospital performance in comparison to other hospitals
  • If you have any questions about this activity, please contact [email protected] .
  • For technical assistance, please contact [email protected] .
  • 4.00 Certificate of Completion

Disclosure Information

In compliance with the ACCME Accreditation Criteria, the American College of Surgeons must ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest.  All reported conflicts are managed by a designated official to ensure a bias-free presentation.  Please see the insert to this program, for the complete disclosure list.

Ineligible Company

Defined by the ACCME as any entity producing, marketing, re-selling, or distributing health care goods or services used on or consumed by patients. Providers of clinical services directly to patients are NOT included in this definition.

Financial Relationships

Relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Conflict of Interest

Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

The ACCME also requires that ACS manage any reported conflict and eliminate the potential for bias during the educational activity. Any conflicts noted below have been managed to our satisfaction. The disclosure information is intended to identify any commercial relationships and allow learners to form their own judgments. However, if you perceive a bias during the educational activity, please report it on the evaluation.

Planning Committee and Disclosures

The Planning Committee was comprised of ACS Staff

Sameera Ali - Nothing to disclose

Claudia Byrd - Nothing to disclose

Mark Cohen - Nothing to disclose

Colleen Fleming - Nothing to disclose

Matt Fordham - Nothing to disclose

Catherine Grant - Nothing to disclose

Ulrike Langenscheidt - Nothing to disclose

Jakob Lapsley - Nothing to disclose

Kitty Vineyard - Nothing to disclose

Continuing Medical Education Credit Information

The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 Credits™

The American College of Surgeons designates this Other activity (semi-annual report review and reflection) for a maximum of 4.0  AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

mbsaqip virtual site visit agenda

Available Credit

You may enroll in the online activity at no charge. You will be asked to register for the course and provide information to complete the registration process.  

Hardware/Software Requirements

To complete this activity, you will need Adobe Acrobat Reader 8 or above.

COMMENTS

  1. PDF Virtual Site Visit Agenda Updated: 2/28/2024

    MBSAQIP Virtual Site Visit Agenda Updated: 2/28/2024 . Expectations and Procedures . 1. After the facility has been approved for a Virtual Site Visit, MBSAQIP will assign a Site Reviewer to conduct the Virtual Site Visit. Confirmation of the assignment may take 1-2 weeks, as Site Reviewers have 7 days to respond to site visit

  2. Raising the Standard: Preparing for Your Virtual Site Visit

    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 ...

  3. PDF Site Visit Savvy 2020

    MBSAQIP Site Visit Agenda v10.1.19 *NEW* MBSAQIP Site Visit Agenda Template MBSAQIP Site Visit Complication List 2019 2019 MBSAQIP Standards ̶Read them! MBSAQIP Site Visit Resources Your guide for MBSAQIP Site Visits Chart Review Prep Full schedule for the day

  4. Site Reviewer Training Course: MBSAQIP

    Preparing for the Site Visit: an overview of scheduling and other pre-site visit responsibilities; Conducting the Site Visit: a detailed walk-through of each component of the site visit; Following Up Post-Site Visit: an overview of what to expect following a site visit; Target Audience. The Site Reviewer Training Course: MBSAQIP is intended for ...

  5. PDF STANDARDS MANUAL

    The MBSAQIP builds upon the rich history of these organizations in surgical patient care and the successes and extensive experiences both have had in administering their individual accreditation and quality improvement programs. The previous version of the standards was enhanced based on feedback received from MBSAQIP-accredited centers and site

  6. MBS Coordinators: Tips, Tricks, & Tools of the Trade

    Description: In this session, MBS Coordinators (novice & experienced) will learn about the necessary steps in preparing for a MBSAQIP virtual site visit, the assistive elements that MBS Directors can provide in navigating your hospital's resouces, QI project development, MBSAQIP tools to ensure program success, & the session will conclude with an interactive networking session between ...

  7. MBSAQIP

    In order to transition to the MBSAQIP, in March of 2012, the ACS signed a memorandum of understanding with the American Society for Metabolic and Bariatric Surgery (ASMBS) to unify their respective bariatric surgery center accreditation programs. As of April of 2012,, all institutions that met the standards under the two separate programs—the ...

  8. MBSAQIP Coordinators

    Describe best practices for organizing documentation and preparing for a virtual site visit. 8:00am: Introduction Kimberly Evans-Labok, BA ... BSN RN; Katie Hiller, BSN RN: 9:15am: MBSAQIP Resources and Tools to Support the MBS Coordinator Role Kimberly Evans-Labok, BA: 9:30am: Break: 10:00am: Virtual Site Visits: How to Prepare Megan Daniels ...

  9. Raising the Standards with MBSAQIP: Part 6 : Bariatric Times

    The following article is the sixth 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 Standard 6 and Obesity Medicine Services (Standards 2.8, 5.6, and 6.4).

  10. MBSAQIP Accreditation

    The MBSAQIP Site Inspection. ... Information about the onsite audit will be provided and the agenda will be reviewed. The post audit review, which takes places one to two weeks after the onsite audit, is a detailed report of the assessment findings with specific recommendations to optimize the organization's readiness for the "official" site ...

  11. Site Reviewer Training Course: MBSAQIP

    Instructions. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Site Reviewer Training course is intended to equip Site Reviewers with the tools and knowledge needed to evaluate sites' compliance with the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Program's standards.

  12. PDF MBSAQIP Standards Optimal Resources for Metabolic and Bariatric Surgery

    A: The annual participation fee for MBSAQIP is all-inclusive for usual costs. It covers access to the MBSAQIP Registry, site visit costs, administrative support, and the plaque/cert ificate issued to centers granted MBSAQIP Accreditation. There may be additional fees for unusual circumstances and one-off requests, such as . off-cycle . site

  13. Metabolic and Bariatric Surgery Accreditation and Quality Improvement

    What Accreditation Means. MBSAQIP accredits inpatient and outpatient bariatric surgery centers in the U.S. and Canada that have undergone an independent, voluntary, and rigorous peer evaluation in accordance with nationally recognized bariatric surgical standards. This accreditation not only promotes uniform standard benchmarks, but also ...

  14. Schedule Overview

    Integrated Health Sessions: MBSAQIP Coordinator Course CEU. In this session, MBS Coordinators (novice & experienced) will learn about the necessary steps in preparing for a MBSAQIP virtual site visit, the assistive elements that MBS Directors can provide in navigating your hospital's resouces, QI project development, MBSAQIP tools to ensure program success, & the session will conclude with ...

  15. Standards

    The revised Optimal Resources for Metabolic and Bariatric Surgery will go into effect October 2022, at which time the MBSAQIP will begin verifying compliance with the updated Standards. Unsupported Browser. The American College of Surgeons website is not compatible with Internet Explorer 11, IE 11. For the best experience please update your ...

  16. PDF Virtual Site Visit Agenda Updated: 9/1/2021

    MBSAQIP Virtual Site Visit Agenda Updated: 9/1/2021 Expectations and Procedures 1. After the facility has been approved for a Virtual Site Visit, MBSAQIP will assign a Site Reviewer to conduct the Virtual Site Visit. Confirmation of the assignment may take 1-2 weeks, as Site Reviewers have 7 days to respond to site visit assignments. 2.

  17. Bariatric Surgery Accreditation

    Accreditation. MBSAQIP works to advance safe, high-quality care for bariatric surgical patients through the accreditation of bariatric surgical centers. The program accredits inpatient and outpatient bariatric surgery centers in the United States and Canada that have undergone an independent, voluntary, and rigorous peer evaluation in ...

  18. PDF Contracts & Agreements

    Centers must submit a complete Pre-Review Questionnaire (PRQ) through the MBSAQIP Quality Portal. The PRQ will be reviewed and approved for site visit by an assigned MBSAQIP Program Coordinator. Once approved for site visit, the center will be assigned a MBSAQIP Site Reviewer. The site visit date will be confirmed with the assigned Site Reviewer

  19. Review and Reflection: MBSAQIP January 2023 Semiannual Report (SAR)

    The American College of Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) January 2023 Semiannual Report (SAR) Review and Reflection activity will give all MBSAQIP Verified Surgeons and MBS Directors the opportunity to collect continuing medical education (CME) credits for the review, reflection, and learning of the January 2023 SAR.

  20. XLSM American College of Surgeons

    Warning: Making changes to the MBSAQIP Site Visit Complication List may break some of the designed functionality. 1. Please use the instructions from the MBSAQIP Site Visit Agenda to identify all applicable complication charts that may be reviewed during the site visit. 2. All identified complications must be entered on the "Complication Data ...