Quality Committees and Projects

Mount Sinai's Department of Surgery actively monitors surgical quality data through a host of oversight committees.

Performance Improvement Committee (PIC)

The Performance Improvement Committee (PIC) is a monthly multidisciplinary meeting in which surgical quality indicators are reviewed and compared against industry benchmarks. Representatives from Colon and Rectal Surgery; General Surgery; Plastic and Reconstructive Surgery; the Surgical Intensive Care Unit (SICU); Surgical Oncology; and Vascular and Endovascular Surgery attend the meeting to provide feedback on their respective indicators. By reviewing surgical quality indicators, our team identifies how we can enhance care and patient safety.

The goal of the PIC meeting is to utilize indicators, which help us track The Mount Sinai Hospital's internal progress each month. Each division within the Department of Surgery tracks trends which pertain to Hospital initiatives, most common complications, and trends within the health care sphere. PIC serves as an open forum for all division representatives to collaborate and provide feedback on surgical quality indicators. Together, we develop deliverables for improvement and for the overall benefit of the patient experience. As a result, we develop more efficient processes to improve patient care.

Given the fast-paced nature of industry benchmarks and managing medical standards of care, the indicators are constantly changing, depending on how each indicator fares each month. When our outcomes data meets acceptable standards of care, a new indicator is assessed. The quality indicators cover topics such as postoperative leaks, outcomes of chemotherapy treatments, operating room equipment, Surgical Care Improvement Project (SCIP) measures, and open chart audit findings for clinical documentation compliance. Each surgical quality indicator is tracked over time to trend results. Any concerning rates are discussed with the Committee to identify root causes of the problem and identify actions and recommendations for resolution. The final minutes of the PIC are submitted to the hospital-wide Performance Improvement Review and Oversight Committee (PIROC).

Performance Improvement Review & Oversight Committee (PIROC)

PIROC focuses on developing methods of improvement for all clinical Departments within The Mount Sinai Hospital. The Committee is responsible for managing clinical processes/systems improvement related to hospital oversight, hospital performance improvement initiatives, certifications (such as the Joint Commission), hospital/institution-wide initiatives, collaboration on current issues as well as address monthly tracked metrics.

PIROC is comprised of an interdisciplinary team of administrators, clinicians, Department heads, performance and quality improvement representatives, and Nursing representatives throughout the Hospital. The diversity of the Committee allows for each representative to express his or her perception and utilization of various issues and items addressed in the meeting. By joining cross-functional teams, the Committee resolves issues on a monthly, bi-annual, or annual basis. Examples include pathology and lab issues (e.g., timing of lab and pathology results), clinical event reporting, and the Patient Complaint Review Committee. The progress of Hospital initiatives, such as becoming certified as a Comprehensive Stroke Center by The Joint Commission, is also shared and reviewed with the Committee.

Each Department is required to present an annual presentation, where an accomplishment and a challenge are presented to PIROC. Feedback is provided by the Committee regarding which area requires additional improvement. It is essential to monitor and track these projects, as each area contributes to the overall efficiency and enhanced patient experience throughout the Hospital.

Quality Assurance Committee and Morbidity and Mortality (M&M) Database

The Quality Assurance (QA) process within the Department of Surgery at The Mount Sinai Hospital is an essential component to ensure patient safety and quality improvement. The foundation of the QA process relies on an internal database, which tracks all morbidities and mortalities within the Department of Surgery. The database tracks all surgical cases on a 30-day timeframe, from a patient's hospital admission to discharge.

Maintaining proper documentation and thorough oversight of the Department of Surgery would not be possible without the accurate event reporting from the residents and surgeons. The information stored in the database – in conjunction with the data collected from The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) – elicits a comprehensive analysis, trending and data for SOQI (the Office of Surgical Outcomes and Quality Improvement) to utilize and to gauge which items need to be addressed, which trends are satisfactory according to national standards, and which items need to be tracked in order to prevent them from happening in the future.

Co-Management Project

In January 2013, Mount Sinai introduced a pilot project started by FOJP (a risk management firm, based in New York City), which focused on the partnership between vascular surgeons and hospital medicine practitioners (also called "hospitalists"), now known as the "Co-Management Project." The Co-Management Project was originally utilized in Orthopaedics, and now, Mount Sinai is paving the way as the first institution to implement a program between Vascular Surgery and hospitalists. Surgical Oncology will soon be added to the program.

The goal of the Co-Management Project is to improve patient care via professional collaboration amongst surgeons and hospitalists. By collaborating with hospitalists in surgical patient care, various benefits include: enhancing the care of and treating the medical needs of surgical patients, management of logistical and clinical issues, and helping to communicate with patients and their families. A professional relationship between surgeons and hospitalists has the potential to elicit a profound and positive influence on patient care in multiple ways.

Evidence shows that the presence of hospitalists allow for better management of hospital resources, which can lead to lower lengths of stay and reduced health care costs for hospitalized surgical patients. In addition, hospitalists provide a unique insight into improving standards of care, best practices, and health care information technology systems because they are closely involved in systemic quality and efficiency improvement efforts inside hospital systems. Quality metrics for the co-management program are also collected in order to gauge the impact of the program. Some statistical variables that are collected include hospital readmissions, in-hospital complication and mortality rates, hospital length of stay, costs of care, overall return on investment for the hospital, and scorecards for measuring patient and professional satisfaction.

Contact Us

Office of Surgical Outcomes and Quality Improvement
Department of Surgery

Phone: 212-241-6509
Fax: 212-410-0111

5 East 98th Street, 15th floor
New York, NY 10029

Surgical Quality Award

congrats spotlightMount Sinai has achieved "Meritorious" status by the American College of Surgeons NSQIP for its quality outcomes in mortality, cardiac, respiratory, and more for all Surgery cases in 2013. Learn more