The year 2002 was a watershed year for the practice of bariatric surgery. At that time, perioperative mortality was reported to be up to 2 % [17], surgery was primarily through open incisions, and any general surgeon could perform a laparoscopic Roux-en-Y gastric bypass (RYGB) regardless of their training, experience, or whether the procedure was accompanied by thorough preoperative and postoperative programs. Highly publicized deaths on television and in print threatened the continued access to bariatric procedures, and malpractice premiums were spiraling higher. The American Society for Metabolic & Bariatric Surgery, the American College of Surgeons, and experienced surgeons from around the country believed that standardization of the education, training, surgery, and program structure was paramount to improve patient safety and effectiveness. In 2004, the Betsy Lehman Center for Patient Safety and Medical Error Reduction was founded in Massachusetts and its first taskforce focused on bariatric care. An expert panel of more than 100 specialists focused on 9 tasks to determine best practices. Their work included not surgical care, the need for a multidisciplinary approach, the need to educate bariatric-specific care at all health-care provider levels, and the importance of a database for long-term success and quality assurance. Their findings set the standard of care for Massachusetts. Because of the growth of bariatric surgery and the development of metabolic surgery, the panel reconvened in 2009 to update its recommendations based on the best evidence [18].

In 2004, the American Society for Metabolic & Bariatric Surgeons (ASMBS) established guidelines for accreditation as a Bariatric Surgery Center of Excellence (BSCOE). The Bariatric Surgeon Review Committee (BSRC) was composed of bariatric surgeons who were responsible for the evaluation of centers for provisional and final designation. They identified ten areas that a bariatric program or hospital must have in order to be considered a BSCOE, with an emphasis on surgical volume (125 cases) as the primary indicator of better quality. The hospitals who applied were site visited and in 2007, a national registry was established. The reporting of data was required to achieve accreditation. In 2012, 458 hospitals had met the criteria to become an ASMBS BSCOE and another 226 were in the process of achieving this distinction [19].

The American College of Surgeons (ACS) developed the Bariatric Surgery Center Network Accreditation Program (BSCN) in 2005. Many ACS recommendations were based on the findings of the Betsy Lehman report. The data on the 30-day outcomes from bariatric procedures was submitted to the National Surgical Quality Improvement Program (NSQIP) Bariatric Surgery Center Network database. That database was built on the platform of NSQIP but required 100 % reporting of cases. The NSQIP database also developed a set of bariatric-specific data to be collected on patients at 30 days, 6 months, and annually. This provides the long-term follow-up needed to further assess the quality and effectiveness of care. As of April 2012, there were 151 institutions that met the criteria for the ACS accreditation to practice bariatric surgery [20].

The ACS and the ASMBS programs evolved to contain a focus on similar elements of care, including process of care, site auditing, and required data reporting. The initial opportunity to begin discussion about merging the two programs came under the leadership of John Baker, ASMBS President, when he initiated a meeting with the newly appointed ACS Executive Director David Hoyt in January 2010. This was followed by Dr. Hoyt giving the Mason Lecture in 2010. In 2011, the ACS and the ASMBS, under the leadership of Robin Blackstone, President of ASMBS, and David Hoyt, Executive Director of ACS, with unanimous support from the ASMBS Executive Council and ACS Board of Regents, developed a unified accreditation program: the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP). As of April 1, 2012, all previously accredited programs in either the ASMBS BSCOE or the ACS BSCN became part of the new program and as of March 1, 2012, began reporting 100 % of all cases to the data registry that had been used by the BSCN. The ASMBS and ACS each nominated equal numbers of surgeons to serve on the standards, data registry, and verification committees. The standards committee, charged with developing unified standards, also includes an integrated health team member. Six of the positions were filled with members of the ASMBS executive council, and in February 2013, all members of the ASMBS executive council joined one of the committees in liaison and oversight roles. The new unified standards are being developed. Unprecedented public input and transparency have resulted in significant improvement to the original design including the addition of surgeon-specific accreditation. Implementation of the new standards should occur by January 1, 2014. Having one set of criteria for accreditation endorsed by the surgical societies will set clear standards for patient experience, surgeons and integrated health teams, hospitals, and payers. The role of each society is complementary: the ACS is better able to give financial and logistical support to the project, while ASMBS offers specialty expertise, dedicated to establishing the content of the standards and developing the collaborative effort to improve safety through analysis of the data [21]. A true partnership has emerged between the two societies.

Reporting patient cases and their course of care to the data registry is the foundation of identifying a hospital as being accredited by the MBSAQIP. The main tenets of data integrity include having a Bariatric Surgery Clinical Reviewer who abstracts data directly from either the hospital or clinic record; having a high percentage of patients included at each data point of 30 days, 6 months, and annually; and reporting 100 % of cases [22]. The data is available in a non-risk-adjusted report for ongoing use for quality improvement at the program level and is produced in a semiannual risk-adjusted report. Although data has been entered by the majority of programs since March 1, 2012, a period of assimilation and familiarity with the database definitions will be required until the data is completely reliable.

The ultimate expression of the data registry is to use the data to improve safe care. The pioneer effort in this aspect of quality came through the Northern New England Collaborative, which was formed in the wake of the publication by the Health Care Financing Administration (HCFA) of the rates of mortality among patients having cardiac surgery. The initial reaction was disbelief, so surgeons formed the collaborative with a commitment to capture the clinical data in order to prove HCFA wrong. To their surprise, they found that HCFA was correct and that there was wide variability in outcomes across the participating centers. They were unfunded, yet had a major impact on the quality of care, driving mortality down in all participants. The modern iteration of this model is the Michigan Bariatric Surgery Collaborative (MBSC). Formed in 2006, the collaborative slowly gained acceptance by most of the surgeons/programs in Michigan. Uniquely, Blue Cross/Blue Shield of Michigan partnered with researchers and surgeons to fund the data collection and provide a forum for evaluation and use of the data. Today, the collaborative meets to discuss data and make decisions about how to direct care based on the risk-adjusted data collected [23]. The MBSAQIP program is designed to build on the examples of the Northern New England Collaborative and the MBSC to foster a national outcome registry that can be used by a collaborative made up of groups of surgeons in each hospital.

In 1952, Dr. Virginia Apgar devised a scoring system to determine the health of a newborn child immediately on delivery. This score improved the immediate care delivered to a child in trouble while allowing for the accurate identification of the problem [24]. In a similar effort, Atul Gawande, MD, and the World Health Organization devised and published the surgical safety checklist in 2008 [25, 26] (Fig. 11.2). Surgical teams use the checklist at certain stages during the operation to help prevent errors and omissions. This can ensure that every person in the room is aware of the type of operation being done, can prepare for it, and anticipates possible events during the case. Studies have shown that implementation of the checklist reduced death and in-hospital complications significantly [26, 27].

The checklist starts with a “sign in” or huddle, which occurs before the induction of anesthesia. At this time, the proper patient, procedure, site, and consent form are confirmed. An anesthesia safety check of their equipment is performed and the patient’s list of allergies and airway/aspiration risk is reviewed. The estimated length of time for the procedure and the likelihood of significant blood loss are determined. After the patient is prepped and draped and before the skin incision is made, a “time-out” is performed. All of the names of the members of the team and their roles are announced to assist with communication. A second confirmation of the correct patient and procedure is done. Critical patient data like allergies to medications and airway difficulty are reviewed. The nursing staff will determine if any special equipment that may be required for the case is in the room. Appropriate antibiotic usage, be it therapeutic or prophylactic, is reviewed. At the end of the case and before the patient leaves the operating room (OR), the nurse verbally confirms what procedure was done (as it may have changed from the one stated preoperatively), that the sponge and needle counts are correct, that the specimen (if any) is labeled properly, and if there were any equipment issues. Finally, the entire team reviews any concerns regarding recovery of the patient. While this appears to be an extensive checklist, some have even advocated for a more detailed preinduction checklist (Table 11.4) [25, 26].

The Surgical Care Improvement Project (SCIP), started in 2006, is another program designed to improve patient care [28]. SCIP measures were initially designed to help prevent surgical infections and thus appropriate use of antibiotics and appropriate hair removal were detailed and reviewed. This product graduated to several preoperative measures designed to help reduce postoperative complications (Table 11.5) [28]. Expert panels then used these results and evidence-based research to detail what the proper care is for several clinical scenarios, for instance, requesting the use of beta-blockers the morning of surgery for those patients who use them and the removal of a Foley catheter on postoperative day one [28]. Several measures of the SCIP are included in Gawande’s surgical checklist. Although there has been some controversy about how patient safety has improved with these measures, the Joint Commission for accreditation of hospitals uses these criteria, in part to determine accreditation; and CMS uses these measures to determine reimbursement. Probably most important is the fact that how an individual hospital does on these national yardsticks of quality is published to the public.

Checklists can also be used as a quick way to identify medical problems. The American Society of Anesthesiologists (ASA) checklist to diagnose sleep apnea is one example [29]. Many obese patients have undiagnosed sleep apnea, which can lead to pulmonary complications in the interoperative and postoperative period. The ASA Obstructive Sleep Apnea (OSA) checklist is a valid test that can predict which patients have sleep apnea and if they are at risk for pulmonary complications (Table 11.6) [30].