PREAMBLE

The Center of Excellence in Abdominal Wall Reconstruction Surgery program is an AWRSC initiative aimed at Indian national patient safety and quality improvement available to all Hernia surgeons and facilities across the nation. The COEAWR program reflects the specific needs of hernia or AWR patients and the unique roles and responsibilities of hernia and surgery providers.

Safe patient care is the result of both the individual surgeon and the facility where the surgery is performed. The COEAWR certification is therefore awarded to a facility and its associated surgeons who have successfully completed the designation process, which enables patients to distinguish providers who have met the state-of-the-art requirements with regards to volume, manpower, and facility for delivering high-quality perioperative and long-term follow-up care.

BENEFITS

• Ensure patient safety.
• Improve the quality of the services offered by both Institutions and Surgeons.
• Ensure highly efficient and safe patient treatment.
• Advise existing Hernia institutions to upgrade their status to a level of excellence.
• A Registry that will guide our decisions and respond to challenges by our colleagues, insurance carriers, health care providers, governments, and the public.
• An invaluable resource for research.

PROGRAM REQUIREMENTS

The primary requirement for applying to COE is that the applicant surgeon should be a Life member of AWRSC at the time of application. The application facility should have a dedicated Hernia surgery department functioning for at least 12 months at the time of application. The department should also have entered their surgical data of at least 3 months of entry:  2 months retrospective and one month of current data.in to the registry by the time of inspection.

SURGICAL EXPERIENCE

The applicant surgeon/facility has performed at least 100 qualifying Hernia surgery procedures in the preceding 12 months for a single surgeon center. If the center has two or more surgeons, then a minimum of 150 surgeries will be required. All the surgeons will be assessed individually. Also, each applicant surgeon has performed at least 200 qualifying Hernia surgery procedures in their lifetime. Application failing to comply with the above clause will not be considered for COE.

Each applicant facility and surgeon should meet surgical outcomes benchmarks for mortalities, complications, readmissions, and re-operations. More surgeons from the same facility can apply for Program Director if he/she satisfies the surgical experience requirement.

QUALIFYING PROCEDURES

All hernia or AWR, MIS, and open surgeries will qualify.

OUTCOMES BENCHMARKS

Applicant facilities and surgeons are required to meet the following outcomes benchmarks.

• Mortality: Overall mortality for all Hernia surgery procedures performed at the applicant facility: less than 0.1% at 90 days
• Complications: ≤10% at 90 days (including major and minor) Bleeding requiring blood transfusion, DVT, Pulmonary embolism, Respiratory failure, SSI, SSO, Sepsis, Intestinal Obstruction, and others.
• Readmissions: ≤5 % at 90 days, Bleeding, Intestinal obstruction, SSI, SSO, Mesh sepsis, Chronic Pain, Other.
• Reoperations: ≤1% at 90 days

PROGRAM DIRECTOR

The applicant/ Hernia surgeon would be the Program Director.
A minimum of three-member Hernia co-ordination committee would need to be constituted following given members, where the surgeon and anesthetist will be the mandatory committee members. More than one Hernia surgeon can be a part of the committee:

The applicant holds interdisciplinary team meetings at least half yearly to ensure that decisions related to Hernia surgery are addressed comprehensively. The minutes of the meetings need to be recorded and uploaded which will be checked by the assessor. The Director would be primarily responsible for coordinating the interdisciplinary services and guidelines for hernia surgery.

CONSULTATIVE SERVICES

This would comprise of:

1. Full-time with 24-hour coverage: A dedicated anesthesiologist team who supervises anesthesia on all hernia surgery patients.
   A fully equipped Intensive Care Unit with a full-time critical care team (CCM) that manages the patient in the immediate postoperative period and during any sudden emergency, respiratory or cardiac arrest through its acute response team.
   anesthetist/surgeon/physician, or, at least one of which is available on-site at all times when patients are present, with an established protocol.
2. On-site within 30 minutes of request:
   Interventional radiologist or other physician capable of performing percutaneous drainage of intra-abdominal abscess.
   An integrated physician with critical care credentials to manage complications.
3. The facility is also able to identify the following consultative staff: Infectious disease specialist, Emergency department, Physiotherapy/Occupational therapy, Ambulance services, and 24-hour laboratory services.

EQUIPMENT AND INSTRUMENTS

The facility has a full line of equipment and surgical instruments to provide appropriate perioperative care for Hernia surgery patients, including:

• Furniture in the OPD.
•  Availability of crash cart in the recovery room and wards where the patients would be shifted in the postoperative period.
• Specific operating room tables to accommodate hernia patients.
• Hernia specific surgical instruments.
• Presence of laryngoscope/bronchoscope if required in OR for difficult airways.
• Radiologic capabilities like CT scan, MRI, Fluoroscopy/dye study, etc. Centers without advanced radiological facilities will need to provide document of MOU with an eligible outsourced facility along with dedicated ambulance services available.

SURGEON DEDICATION/QUALIFIED CALL COVERAGE

The applicant facility should have policies and guidelines in place that require applicant/all eligible Hernia surgeons to have qualified call coverage, and the applicant surgeon certifies that each covering surgeon is capable of identifying and treating Hernia surgery complications.
The applicant surgeon spends a significant portion of his efforts in the field of Hernia surgery and completes continuing medical education. The applicant surgeon is a general/ gastrointestinal surgeon by the highest certifying authority and is a life member of AWRSC. The applicant surgeon has privileges as both a Hernia and general surgeon at the applicant facility. The application facility should have a dedicated department of Hernia and surgery under which all the protocols, guidelines, and SOPs are functioning. The applicant facility also should have Clinical Pathways for each service provided.

STANDARDIZED OPERATING PROCEDURES

The applicant formally adopts and implements clinical pathways that facilitate the standardization of perioperative care for the relevant procedure:

• Preoperative multidisciplinary evaluation, education, preparation, admission workup/evaluation, and informed consent of the Hernia surgery candidate.
• Anesthesia, including monitoring and airway management.
• Perioperative care, including monitoring and airway management.
• Deep vein thrombosis (DVT) prevention.
• Identification and evaluation of early warning signs of complications.
• Pain management.
• Postoperative Follow up including entering data in the AWRSC Registry.

PATIENT EDUCATION

The applicant provides organized and supervised education for all patients who may undergo or have undergone Hernia surgery regularly. 24-hour helpline number to be provided for emergency calls and tele-consult / counseling services.

CONTINUING MEDICAL EDUCATION

The applicant/facility would be committed to spreading the science of safe Hernia surgery. At least one course/ CME would be attended every year by the surgeon.

ONSITE INSPECTION FOR ACCREDITATION

This accreditation will be a “Level One” Centre of Excellence.

1. The application for the accreditation will be filled online through the official AWRSC website www.awrsurgeons.com.
2. The application will be accompanied by an online application fee of Rs 10,000/- payment to the AWRSC account.
3. After receiving the fees AWRSC COE committee will credential the application and if approved, will appoint two assessors for an onsite inspection.
4. The cost of traveling and local hospitality for the assessors will be taken care of by the applicant.
5. After the inspection, if the facility is approved, and communicated by email, the COE will pay an additional Rs 1,00,000/-within two weeks. Then the certificate for COE will be given to the applicant/center. The accreditation will be valid for 2 years.
6. If some deficiencies are found in the inspection, the center/applicant will be
   given a period of up to three months, for correction of the deficiencies. If after re-evaluation, still the application fails to achieve a successful grant of COE, then the COE committee will make a final decision about the award or non-award of the COE.
7. After two years, renewal of the accreditation will be done by an online process and the renewal fees will be after 2 years, the amount of which will be notified in due course of time.

MISCELLANEOUS

If the Program Director leaves the facility, it will cease to exist as a “Centre of Excellence”. A fresh application with a new Program Director with all the required documentation would be needed to reapply and meet the desired criteria. The rules and fees for the new center will be applicable as new.

Directors COEAWR

Dr Arun Prasad

Dr Rahul Mahadar