preliminary standards. Working with 58 national stakeholder organizations, the CQGS team developed 308
preliminary standards under four domains: continuum of care, clinical care, program management, and
patient outcomes and follow-up. Following an extensive
RAND-based review process, the project team settled
on 88 standards, which will be released for additional
stakeholder comment in January 2017 (see related article, page 22).
The first-draft standards of the soon-to-launch
Children’s Surgery Verification (CSV) program were supported
by the Society of Pediatric Anesthesia and the American
Pediatric Surgical Association. The pilot phase of the
program launched in April 2015, and within a month,
six site visits were completed. The experiences of the
pilot sites and surveyors confirmed that the standards
are applicable, clear, and measurable. Nearly 125 sites
have expressed interest in pursuing verification. The
Children’s Hospital Association strongly supports this
initiative and estimates that 200 hospitals will participate in the CSV program. The full CSV program is
scheduled to launch later this year.
At present, 813 centers participate in the Meta-
bolic and Bariatric Surgery Accreditation and Quality
Improvement Program (MBSAQIP), 725 of which are fully
accredited. From October 2014 through August 2016,
655 site visits had been completed using the MBSAQIP
standards, and 61 surgeon surveyors are expected to
perform 270 site visits this year.
The second version of the MBSAQIP standards took
effect October 1, and ongoing education is being pro-
vided to assist centers in compliance.
The Decreasing Readmissions through Opportunities Provided (DROP), the first MBSAQIP national
quality collaborative project, has concluded, and the
MBSAQIP Quality Subcommittee has launched the next
national project, Employing New Enhanced Recovery Goals to Bariatric Surgery, which seeks to enhance
patient experiences through improved pain management, fewer opioid side effects, decreased readmissions,
and quicker return to normal activity.
ignated as a PQRS Qualified Clinical Data Registry
(QCDR) for the third consecutive year. Public reporting at the surgeon level has been added where required
by CMS and will be displayed on both the MBSAQIP
website and the CMS Physician Compare site.
The ACS continued development of the Surgeon
Specific Registry (SSR) as a tool for surgeons to log
and track cases and comply with certain regulatory
requirements. The following three reporting options
are again available through the SSR for surgeons participating in the 2016 PQRS reporting cycle:
• General Surgery Measures Group for general surgeons
•Individual Measure reporting for surgical specialties
(PQRS-Qualified Registry)— 43 PQRS individual measures for surgeons across several specialties
• QCDR, including trauma measures, for trauma surgeons
The ACS has proposed the use of Phases of Care
Measures, which are inclusive of multiple subspecialties. ACS Clinical Scholars used several ACS Quality
Programs, including the CQGS project, to align the
measures. In July, the measures were submitted to
CMS for inclusion in the Measures under Consideration list.
The Division of Research and Optimal Patient
Care (DROPC) and DAHP are collaborating to prepare for upcoming implementation of MIPS in 2017.
An SSR Quality Advisory Committee provides guidance, expertise, feedback, and user experiences on
quality measurement through the SSR, especially
The College continues work on the quality manual,
which is being drafted to help health care institutions
improve quality processes and outcomes. The final
phase of editing is under way, as is exploratory work
to evaluate the feasibility of developing an adjunctive
or integrated Surgical Quality Verification Program.