To report the verification measure, the facility or physician group practice must be an accredited bariatric center, which means it has met all the 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) or similar program standards; at present more than 90 percent of bariatric surgery operations occur in MBSAQIP hospitals or practices. The goal of the measure is to incentivize accredited bariatric centers to go beyond basic compliance of standards and to consider how to further enhance efforts to become exemplary models of care. In other words, as part of BPCI-A, the Centers for Medicare & Medicaid Services (CMS) will reward hospitals and surgical care centers that show an exemplary commitment to continuous QI.
The verification measure includes six structural domains to score the bariatric surgery clinical episode, which were chosen from the 41 program standards. The score is determined based on whether a verified center “meets” the criteria enumerated in the standards, “exceeds” the criteria, or is considered “exemplary” based on the criteria. The score from this measure, along with other quality measures in the bariatric surgery quality measure set, is then used to adjust the reconciliation amount for the bundled payment relative to a target set based on historical data specific to that participant.5 The six MBSAQIP standards chosen for the measure domains are firmly linked to an infrastructure that promotes safer and higher quality of care as follows:6
- An MBS committee—to promote multidisciplinary discussion, communication, and decision making
- An MBS director—to promote leadership
- Patient education pathways—to promote standardized education and patient inclusion
- Patient care pathways—to promote reliability and effectiveness
- Adverse event monitoring—to promote continuous quality evaluation
- QI initiatives—to promote continuous quality improvement and outcomes
One example of how a participating group or hospital would achieve a score that “exceeds” the Quality Improvement Initiatives Standard is to demonstrate an increasing number of QI initiatives beyond the documentation of one QI—the minimum standard—as illustrated in Table 1. To be designated as “exemplary” a facility could engage in multiple QI activities and document improvements in patient outcomes, which will allow for increasing opportunities to surpass the current evidence-based standard to motivate the multidisciplinary team to work together to raise the ceiling on care on a systemwide or department-wide level.
It is worth noting that although the score itself only considers six standards, compliance with all of the MBSAQIP clinical program standards must be met to report this measure for the bundled bariatric episode. The reason for this approach is that the bariatric verification measure incentivizes adherence with the full clinical program, which is organized on the basis of the patient’s condition, similar to the integrated practice unit (IPU) framework, as described by Porter and colleagues.7 The organization of these programs is first and foremost multidisciplinary, yet also integrated for optimal care of a patient’s condition. Thus, the scored standards included in the verification measure were chosen because they highlight the multidisciplinary and integrated nature of the MBSAQIP program, including the multidisciplinary MBS committee; the MBS director, who integrates the different program components; QI, which requires contributions from multiple disciplines and integration for improvements, and so on.
It will be critical to obtain the comprehensive nature of this measure for future iterations or similar measures in other conditions. If standards are separated and processes or outcomes looked at in silos, the totality of a quality program is not considered and, unfortunately, can fall apart. The entire program must be valued altogether, where the sum is greater than the parts. As we initiate this endeavor, the reason we’re looking at a limited number of standards to be scored in the first iteration of the measure is for scaling purposes.*
The goal of future implementations, however, is to score additional standards, beyond the initial six, to help program participants move compliance even further toward providing increasingly higher-quality care—without increasing burden—to best serve their local patient population.
*Although only a subset of facilities will participate in BPCI-A and be scored, those participants will be benchmarked with all verified bariatric centers.
Implementation of a quality program framework
The verification measure focuses on a bariatric clinical accreditation quality program because it gauges the quality of the BPCI-A Bariatric Surgery Clinical Episode. However, in the future, a quality program framework that specifically targets surgical quality improvement could, and should, be implemented so that the hospital will support, evaluate, and improve surgical quality care across all surgical departments and include all surgical procedures (regardless of the presence of a formal clinical program, procedure volume, and so forth). The QI program includes such attributes as demonstrable commitment to surgical quality from the C-suite; appointment of a surgical quality officer and surgical quality committee; establishment of a hospital safety culture; a formal case review process; standard surgeon onboarding, credentialing, and privileging policies; data systems organized to find problems (such as complications and inefficiencies) and fix them; and so on.
The ACS Quality Verification Program is the ACS quality program for achieving QI for use across the House of Surgery.8 This standards program draws from Donabedian’s structure, processes, and outcomes quality model, which has proven to be an effective way to conceptualize quality of care.9 As mentioned earlier, the ACS’ assertion that surgical quality should be delivered and measured as a full program fundamentally operationalizes the entire Donabedian quality model. Figure 1 conceptually demonstrates the layers for achieving surgical quality with the ACS Quality Verification Program at the base. This program sets the standards for structure and process components by defining the resources, infrastructure, and processes needed to achieve optimal QI.
The ACS Clinical Programs set the standards for clinical care and these programs are where condition- or specialty-specific (such as Bariatric, Trauma, Geriatrics) standards are added. Layering on top of clinical accreditation are appropriate and adequate processes that further help to implement the care model. Moving up in the hierarchy of the key components are monitoring of clinical outcomes with accurate, clinical, risk-adjusted data—the model used in the National Surgical Quality Improvement Program (ACS NSQIP®)—followed by outcomes reporting by the patient, or patient-reported outcomes (PROs). Each component of the quality model builds on and is interrelated to the others, pulling the information to assess the essential components for a patient, allowing for patients, clinicians, and payors to assess more completely the quality of care. The ideal for the systematically organized set of measures is to represent the spectrum of an effective quality program by focusing on each layer of this pyramid.
Challenges and opportunities
It is important to recognize that although the quality as a program framework has proven to drive higher quality in surgery and is more meaningful than the status quo to surgical teams, there always are challenges to any new change. We anticipate challenges and opportunities regarding communicating and implementing a new way of thinking about quality evaluation and improvement. Yet there also is great opportunity to identify how best to scale a quality program in an equitable way given the broad spectrum of settings, types of hospitals, resources, and surgical specialties.
