ASK MBSAQIP Agenda ASK MBSAQIP December 8, 2016 Time (CST) Agenda Item Panelist 12:00 Noon Welcome & Introductions Tanya Kimber 12:10 – 12:45 PM Accreditation and Standards Amy Robinson- Gerace Teresa Fraker Leticia Jones Paul Jeffers 12:45 – 12:50 PM Standard 5.3 30 Day and Long-Term Follow-up Lisa Hale 12:50 Q & A All ASK MBSAQIP December 8, 2016

ASK MBSAQIP House Rules & Technical Tips Questions Questions submitted prior to 12 Noon CST on December 5, 2016 will be answered first. Questions will be displayed on screen, panelists will answer the question aloud. Control Panel Audio Pane – Use the Audio pane to switch between Telephone and Mic & Speakers. The bottom of the audio pane indicates who is presenting. You are muted by default. Questions Pane – If you wish to ask a question, click on the question pane on your control panel and type in your question. We will address these questions at the end of the call.

Why is my question not listed? 1. You submitted a Data Registry or Clinical Question. Please submit those questions to our clinical inbox: clinicalsupport@mbsaqip.org 2. You submitted a question after 12 Noon CST on Monday, December 5th 3. Clarity. We could not fully understand your question. 4. Length. GoToMeeting has a character max. Please call or email MBSAQIP with lengthy or complex questions. 5. We want to get to everyone’s question so if you do not see your question here, please email us at mbsaqip@facs.org or submit to our next call on January 12, 2017! ASK MBSAQIP December 8, 2016

Accreditation and Standards Panelist Amy Robinson- Gerace Accreditation Services Manager, MBSAQIP ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: What is the process for going from Comprehensive to Comprehensive with Adolescent designation? ASK MBSAQIP December 8, 2016

Accreditation and Standards Standard 2.4 Q: Can you clarify “not charting on patients” in the MBS Coordinator/MBSCR role? ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: Should we abstract for out patient procedures performed at another facility? ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: When will reaccrediting centers renewal applications be made available? ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: If the MBS Director leaves prior to the site visit, can the other bariatric surgeons step into this role? ASK MBSAQIP December 8, 2016

Accreditation and Standards Standard 7.2 Q: Can you provide more details on the requirements for the QI projects? ASK MBSAQIP December 8, 2016

Accreditation and Standards Standard 7.3 Q: Will a reminder be sent requesting the Annual Compliance Report (ACR)? ASK MBSAQIP December 8, 2016

Accreditation and Standards Panelist Teresa Fraker Program Administrator, MBSAQIP ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: Will there be a session for MBSCR’s at the NSQIP conference next year? ASK MBSAQIP December 8, 2016

Accreditation and Standards Standard 2.9 Q: Can all three training sessions be met with one class? ASK MBSAQIP December 8, 2016

Accreditation and Standards Standard 3.1 Q: Can you give an example of a care pathway for patients who exceed equipment weight limits? ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: Are the handouts from the Quality Improvement Course at Obesity Week available? ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: Is it required that patients receive physical therapy when in the hospital? ASK MBSAQIP December 8, 2016

ASK MBSAQIP December 8, 2016

ASK MBSAQIP December 8, 2016 PUF Coming Soon!! SAR-7 in January, 2017   PUF Coming Soon!! SAR-7 in January, 2017 The MBSAQIP® will be releasing the inaugural 2015 Participant Use Data File (PUF) – which includes cases with operation dates between January 1, 2015 and December 31, 2015. PUF is a Health Insurance Portability and Accountability Act (HIPAA)-compliant data file containing cases submitted to the MBSAQIP Data Registry. The PUF contains patient-level, aggregate data and does not identify hospitals, health care providers, or patients. The intended purpose of this file is to provide researchers at participating sites with a data resource they can use to investigate and advance the quality of care delivered to the metabolic and bariatric surgical patients through the analysis of cases captured by MBSAQIP. Please expect the  announcement with PUF information and guide for centers soon!! Future MBSAQIP SARs are anticipated to be released in January and July every year. The next SAR-7 is anticipated to be released in January 2017 and will include six months of data from the previous SAR-6, analyzing cases with operative dates between July 1, 2015 and June 30, 2016. ASK MBSAQIP December 8, 2016

Accreditation and Standards Panelist Paul Jeffers, MBSAQIP Verification Specialist ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: For the site visit, is there anything else we should focus on besides what’s on the agenda? ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: Will charts for complications need to be prepared or can a list be provided for electronic review? And would you recommend using binders for the chart review? ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: If the surgeon’s office is in the same building as the facility, will the site surveyor request to visit the surgeon’s office? ASK MBSAQIP December 8, 2016

Accreditation and Standards Panelist Leticia Jones, MBSAQIP Program Assistant ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: Are we allowed to start entering cases into the data registry if we are currently waiting for our site visit to become accredited? ASK MBSAQIP December 8, 2016

Accreditation and Standards Q: What is the process for notifying MBSAQIP when a position becomes open, i.e. Coordinator, MBSCR, Director? ASK MBSAQIP December 8, 2016

Accreditation and Standards Panelist Lisa Hale, Clinical Support Specialist ASK MBSAQIP December 8, 2016

30 Day Follow-up

What is Full 30 Day Follow-up?

What is Full 30 Day Follow-up?

Full 30 Day Follow-up Examples

Full 30 Day Follow-up Examples Only if signed off by

Follow-up Call and/or Letter When is it necessary to make a call and/or send a letter?

Follow-up Call and/or Letter When is it necessary to make a call and/or send a letter?

30 day postoperative clinical course Why is it necessary? Obtain a complete picture of the patient’s entire 30 day postoperative clinical course

Follow-up Call What would be asked? Phone call with Provider does not count

Follow-up Letter

? QUESTION: Full 30 Day Follow-up A B The patient has a visit on postoperative day 15 with the NP at the center. An appointment was made for postoperative day 60. The patient called to reschedule and set-up an appointment for postoperative day 95. Would this be considered full 30 day follow-up? Yes A No B

? QUESTION: Full 30 Day Follow-up A B As there is no information for the patient beyond the assessment on postoperative day 15, this would not be considered full 30 day follow-up. As the patient’s next appointment is outside of the 90 day lock date, the MBSCR would need to attempt to contact the patient to obtain full 30 day follow-up for this case. Yes A No B

? QUESTION: Full 30 Day Follow-up A B The patient died on postoperative day 25. Would this be considered full 30 day follow-up? Yes A No B

? QUESTION: Full 30 Day Follow-up A B Intraoperative death and death from postoperative day 0 through postoperative day 30 is considered full 30 day follow-up. Yes A No B

? QUESTION: Full 30 Day Follow-up A B The patient has an assessment on postoperative day 12 with the MBS surgeon and called the center on postoperative day 35 with complaints of a UTI. A prescription is called in by the NP for Bactrim for a UTI. Would this be considered full 30 day follow-up? Yes A No B

? QUESTION: Full 30 Day Follow-up A B As there is no information for the patient beyond the assessment on postoperative day 12, this would not be considered full 30 day follow-up. T the MBSCR would need to attempt to contact the patient to obtain full 30 day follow-up for this case unless there is an appointment scheduled with a provider (MD, DO, NP, PA) at the center prior to postoperative day 90. Yes A No B

? QUESTION: Full 30 Day Follow-up A B The patient has an assessment on postoperative day 16 with the PA at the center and a physical assessment with the bariatrician at the center on postoperative day 45. Would this be considered full 30 day follow-up? Yes A No B

? QUESTION: Full 30 Day Follow-up A B As a physical assessment was completed by the bariatrician at the center on postoperative day 45, this would be considered full 30 day follow-up. Yes A No B

? QUESTION: Full 30 Day Follow-up A B The patient has an assessment on postoperative day 14 with the NP at the center. There were no further appoints made with the center. In the chart, there is a physical assessment with the patient’s PCP on postoperative day 45 which notes that the patient has been “doing well” since the metabolic/bariatric surgery. Would this be considered full 30 day follow-up? Yes A No B

? QUESTION: Full 30 Day Follow-up A B As there is a physical assessment with the patient’s PCP on postoperative day 45 which mentions the metabolic/bariatric surgery, this would be considered full 30 day follow-up. Yes A No B

? QUESTION: Full 30 Day Follow-up A B The patient has an assessment on postoperative day 20 with the MBS Surgeon and a visit with the dietician at the center on postoperative day 45 which notes that the patient has had an uneventful recovery. The dietician’s note is signed off by the surgeon. Would this be considered full 30 day follow-up? Yes A No B

? QUESTION: Full 30 Day Follow-up A B As the patient had a visit with the dietician at the center on postoperative day 45 which notes that the patient has had an uneventful recovery, and was signed off by the surgeon, this would be considered full 30 day follow-up. Yes A No B

? QUESTION: Full 30 Day Follow-up A B C The patient has a physical assessment with the MBS Surgeon on postoperative day 14. The patient required no further follow-up with the surgeon. What action(s) would be required? The MBSCR would make a call and/or send a letter to the patient in an attempt to obtain full 30 day follow-up after postoperative day 30 A The MBSCR would review the medical record to see if the patient had a assessment on or after POD 30 with another provider in which the MBS surgery or associated hospitalization was mentioned B The MBSCR would check the local obituaries C

? QUESTION: Full 30 Day Follow-up A B C The MBSCR would review the medical record to see if the patient had a assessment on or after POD 30 with another provider in which the MBS surgery or associated hospitalization was mentioned. If there was no such documentation available, the MBSCR would make a call and/or send a letter to the patient in an attempt to obtain full 30 day follow-up after postoperative day 30. Prior to the lock date, if the MBSCR was not able to contact the patient, they would check the local obituaries. The MBSCR would make a call and/or send a letter to the patient in an attempt to obtain full 30 day follow-up after postoperative day 30 A The MBSCR would review the medical record to see if the patient had a assessment on or after POD 30 with another provider in which the MBS surgery or associated hospitalization was mentioned B The MBSCR would check the local obituaries C

Additional Questions? At this time we will answer any questions typed into the questions pane. We will answer as many questions as possible, time permitting. ASK MBSAQIP December 8, 2016

Thank You for attending ASK MBSAQIP! Please join us for our next ASK MBSAQIP! Call on Thursday, January 12, 2017 at Noon CST