American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Metabolic and Bariatric Surgical Clinical Reviewer Requirements

  • Accurate, complete, and timely data entry is essential to ensure continuous quality improvement which will ultimately enhance patient safety and associated excellence in outcomes.
  • Each Center is required to assign at least one MBSCR to input data into the MBSAQIP Data Registry Platform. A single backup MBSCR can be assigned, if needed. It is highly recommended to submit a MBSAQIP Data Registry Access Form as soon as possible to allow adequate time for online training and site activation.
  • MBSCRs must be assigned by the Center. It is the Center’s responsibility to ensure that the MBSCR is in compliance with the terms of the Business Associate and Data Use Agreements as executed between the ACS and the Center (Covered Entity) to ensure the confidentiality of patient health information and HIPAA compliance.
  • Prior to registering an MBSCR to begin training or data entry, the Center must submit a Pre-Application to become either a Data Collection Center or Accredited Center, remit the participation fee, and fully execute the MBSAQIP Participation and Business Associate and Data Use Agreements.
  • MBSCRs must successfully complete the initial online training modules with a score of 90% or higher prior to receiving access and beginning data collection to the MBSAQIP Data Registry Platform.
  • Maintenance of MBSCR Certification is required and is based upon successful completion of initial online training, participation in ongoing educational webinars, educational questions, satisfactory completion of a yearly certifying exam, and compliance with data audits.
  • MBSCR is required to make attempts to capture 30-day and long-term follow-up (LTFU) data over time (6 months post-op and annually thereafter) within prescribed assessment and data entry periods as outlined in the MBSAQIP Workstation. Additionally, the MBSCR may need to fulfill requests for patient data and reports to the MBS Coordinator and other appropriate personnel for analysis.
  • MBSCRs must work closely with both clinical and administrative staff and participate in at least two MBS Committee meetings annually.
  • It is required that the MBSCRs have access to all patient-related data from the institution and physician’s office(s) that is required to be submitted to MBSAQIP.
  • Designated MBSCRs are not permitted to be involved in supervising patient care, for example, a surgeon, a physician assistant or advanced practice nurse, and may not chart on any of the variables collected in the MBSAQIP workstation. Please see the MBSCR Hiring Recommendations and MBSCR Job Description for a full description of this role.
  • The Metabolic and Bariatric Surgery (MBS) Director at the Center will be provided with read-only access to the MBSAQIP Data Registry Platform. Training is not required for read-only access.
  • The Center is required to immediately notify MBSAQIP if any personnel should no longer have access to the MBSAQIP Data Registry Platform.
  • Please note that MBSCR cannot also serve as the primary SCR for ACS NSQIP. The MBSCR may be a backup SCR for ACS NSQIP and vice versa.