Learning Objectives

  1. Describe the necessary components of documentation & preparing a center for a successful site visit.
  2. Discuss various ideas for QI projects, pursuant to the MBSAQIP standard for quality improvement.
  3. Review toolkits that assist centers in their QI projects, inclusive of surgical site infections, readmissions, & urinary tract infections.


During this highly interactive session attendees will learn the history of MBSAQIP, important changes to the MBSAQIP standards, site visit preparation & best practices, as well as various MBSAQIP tools to support centers’ quality improvement & accreditation efforts. Ample time will be provided for group discussion(s) between participants as well as the MBSAQIP staff, who will serve as the content experts for this course.

1:15pm Welcome
Teresa Fraker, MS RN
1:20pm The History of MBSAQIP
Jaime Thomas, MHA
1:35pm MBSAQIP Standards Version 3.0: What's New?
Paul Jeffers, BA
1:50pm Site Visits: A "How To" Guide (including breakout discussions)
Paul Jeffers, BA
2:45pm Accreditation Tools for Centers: What You Need to Know (ACR, ADT, Quality Meeting Tracker, & Complication List)
Leticia Jones
3:00pm QI Tools for Centers: What You Need to Know (SSI, UTI, & Readmission Toolkits)
Kaynaat Syed, MHA BS
3:15pm Break
3:45pm MBSAQIP Trivia
Lisa Hale, MSN RN CNOR
4:30pm Review of Endorsed Procedures & Networking Tools from ASMBS
Teresa Fraker, MS RN
4:45pm Closing (Q&A)
Teresa Fraker, MS RN; Jaime Thomas, MHA; Paul Jeffers, BA; Leticia Jones; Kaynaat Syed, MHA BS; Lisa Hale, MSN RN CNOR; Jesus Diaz, MSN RN
5:00pm Adjourn