The department of surgery at my hospital, Mount Sinai Medical Center in New York City, decided the financial success of our bariatric program hinged on gaining accreditation as a Center of Excellence. You may recall that the federal government ruled in February that Medicare would reimburse only for reasonable and necessary bariatric procedures performed in facilities recognized as Centers of Excellence by the American Society for Bariatric Surgery or as Accredited Bariatric Surgery Centers by the American College of Surgeons. The classifications ensure that bariatric programs fulfill high quality levels in many different areas, and that's attractive to patients and referring physicians alike. Here's how we got our program certified.

Facility requirements
Deciding between the ASBS and ACS is the first step when seeking this accreditation. The ASBS was the first to establish a national certification and was the only option available when we began the accreditation process. My experience lies with the ASBS, though both organizations are more similar than different. One difference is that the ACS certifies a hospital, while the ASBS certifies the facility, the surgical group and the individual surgeons who will perform the surgery (see "Working With the ACS" on page 58).

The ASBS works in conjunction with the Surgical Review Corporation, a non-profit organization that investigates applicants to ensure the facilities meet established standards for recognition as a Bariatric Surgery Center of Excellence. According to ASBS policy, hospitals applying for certification must have an annual volume of 125 bariatric surgeries with surgeons who each perform 50 or more procedures each year.

Hospitals must also meet SRC accreditation standards and confirm these requirements during a planned site visit by SRC surveyors. The time required to prepare for the site visit depends on what your facility already has in place. Here's what we needed to address and document as we prepped to receive the SRC surveyors.

• Culture change. Staff should be prepared to manage obese patients with understanding and compassion. This was a big challenge. The surgeons and OR staff who work frequently with obese patients are sensitive to the physical and emotional challenges they face. Many of the hospital's ancillary employees weren't. We developed a hospital-wide sensitivity awareness program to reach every individual along the bariatric patient's surgical track. From the transport staff to X-ray techs, we ensured that employees understood obese patients are real people with real feelings who deserve to be treated with respect and dignity.
• Experienced leader. I serve as the bariatric surgery medical director, as required by the SRC and appointed by the hospital's administration. As outlined by the SRC, my responsibilities entail organizing ongoing educational in-service programs for the bariatric center's staff. I also coordinate bi-weekly meetings with representatives of the department of surgery, nursing supervisors, intensive care, inpatient and outpatient departments, physical therapy, transportation staff, the business office and central supply. These meetings open lines of communication, create a sense of teamwork throughout the hospital and let departments share challenges and solutions in the care of our bariatric patients.
• Specialized equipment. The SRC and ACS require that furniture, beds, scales, wheelchairs, OR tables and stretchers are extra-wide and strong enough to accommodate the severely obese. The accrediting groups also require patient movement and transfer systems in to be place throughout the institution. Finally, hospital employees must be capable of safely moving obese patients.

Our patient care areas were already up to SRC standards. The beds were appropriate for obese patients, chairs in our waiting room and offices were oversized and we employed HoverMatts to slide patients from one bed to another. We discovered, however, that small infrastructure details were not up to SRC standards.

Specifically, our hospital's toilets were wall-mounted, for easier cleaning of the bathrooms' floors. But the SRC requires floor-mounted units for adequate support of obese patients, a mandate that necessitated the replacement of all our toilets. Meeting ASBS standards also entailed the purchase of new commodes and wheelchairs designed for obese patients.

• Expert nurses. Hospitals must have staff nurses who routinely care for bariatric patients, according to SRC policy. These nurses should have access to bariatric surgery continuing education courses and must demonstrate an ability to recognize common complications of bariatric surgery, including pulmonary embolus, anastomotic leak, infection and bowel obstruction.
• Post-op care. Patients considering weight-loss surgery at Mt. Sinai meet with the bariatric surgeon, nurses or physician assistant, a psychologist or psychiatrist, a gastroenterologist and a nutritionist. Our team approach ensures patients understand all options before determining the most effective and appropriate treatment.

Accredited bariatric programs must demonstrate a similar level of commitment to the patient's post-op care. SRC surveyors look for documented evidence of support groups for obese patients, including meeting times, topics covered and patient attendance.

Applicants are required to establish a system to track the outcomes of at least 75 percent of bariatric procedures at five years post-op. Outcome reports must also be submitted to the SRC on an annual basis.

Physician quotas
The SRC, in accordance with ASBS policy, wants to see evidence of minimally acceptable credentials for surgeons to be eligible for hospital privileges. Each applying surgeon must have credentials to perform gastrointestinal and biliary surgery and document that he's involved in a fully integrated program for the care of the morbidly obese (including dietary instruction, counseling, support groups, exercise training, programs to prevent short-term and long-term complications and encourage follow-up for all patients).

To obtain privileges for open bariatric surgery, physicians must show documented experience of 15 open procedures with satisfactory outcomes occurring during general surgery residency or under the supervision of an experienced bariatric surgeon (the ASBS and SRC define experienced surgeons as physicians who have performed 200 bariatric procedures). Surgeons who primarily perform laparoscopic bariatric procedures can obtain open privileges after documenting 10 open cases supervised by an experienced bariatric surgeon.

A surgeon applying for laparoscopic privileges for cases involving the stapling or cutting of the gastrointestinal tract must already be credentialed to perform open procedures, have privileges to perform advanced laparoscopic surgery at the accredited facility and document 50 cases with satisfactory outcomes that occurred during general surgery residency or under the supervision of an experienced bariatric surgeon.

Surgeons applying for certification of laparoscopic procedures that don't involve stapling of the gastrointestinal tract must have privileges to perform advanced laparoscopic surgery at the accredited facility and document 10 cases with satisfactory outcomes.

In addition to meeting ASBS quotas, SRC expects surgeons to enact policies that outline standardized care for the uncomplicated patient. The surgical teams working with each surgeon should follow identical clinical protocols, allowing comparison of the outcomes achieved by each of the hospital's surgeons.

Weight-loss gains
It was easy to get Mt. Sinai's ORs prepped to meet SRC standards. Getting the entire hospital involved in the process was a substantial challenge. Talk of change in surgical facilities usually involves a doc champion. I may have led the charge, but I certainly didn't work alone. As the hospital worked toward becoming a Center of Excellence, I had to rely heavily on dedicated bariatric staff in many departments who were willing to ensure Mount Sinai met the high level of quality demanded by the SRC.

Our preparation involved a facility-wide, 12-month effort that culminated in Mount Sinai's gaining accreditation last July. It was a long, arduous process, but the exercise brought our hospital's leaders together as we focused on a common cause and improved patient care. The hard work also prepared our facility for the current realities of Medicare reimbursements. Since local carriers usually follow Medicare's lead, we now feel confident about the future growth of our bariatric program.