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) is a monthly multidisciplinary meeting where we look at our surgical quality indicators, compared against industry benchmarks. The multidisciplinary team includes 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. Our goal is to identify how we can improve patient care, increase efficiency, and to track our progress every month. We look at a wide variety of areas of patient care, including postoperative leaks, outcomes of chemotherapy treatments, operating room equipment, Surgical Care Improvement Project measures, and open chart audit findings for clinical documentation compliance. We track each of these areas over time to spot any trends and submit our final minutes to the hospital-wide Performance Improvement Review and Oversight Committee (PIROC).

Performance Improvement Review and Oversight Committee (PIROC) focuses on developing methods to improve care in all clinical departments in The Mount Sinai Hospital. We manage clinical processes related to hospital oversight, hospital performance improvement initiatives, certifications (such as The Joint Commission), hospital/institution-wide initiatives, and collaboration on current issues. We track results on a monthly basis.

PIROC is comprised of an interdisciplinary team of administrators, clinicians, department heads, performance and quality improvement representatives, and nursing representatives throughout the hospital. We look at areas such as the pathology and lab issues (e.g., timing of lab and pathology results), clinical event reporting, and the Patient Complaint Review Committee. We are also involved with hospital-wide initiatives, such as becoming certified as a Comprehensive Stroke Center by The Joint Commission. Every year, each department in the hospital presents its accomplishments and challenges to the PIROC, and we provide feedback about areas for improvement.

The Quality Assurance Committee relies on an internal database, the Morbidity and Mortality (M&M) Database, which tracks all morbidities and mortalities within the Department of Surgery from the time of admission until 30 days after surgery. This information, in conjunction with the data collected from The American College of Surgeons National Surgical Quality Improvement Program (NSQIP), enables us to comprehensively analyze trends. We gauge which trends are satisfactory according to national standards, and which items we should track and address.