Quality Initiatives

The American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®)

The American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) helps hundreds of hospitals across the country gauge the quality of their surgical programs through the collection of data that provides fair, in-depth and insightful analysis. This data helps surgeons and hospitals better understand their quality of care compared to similar hospitals with similar patients. The Mount Sinai Hospital was recognized for meritorious outcomes for surgical patient care for three consecutive years (2015-2017) by ACS NSQIP®, being one of only five hospitals to receive the status in three consecutive years as of 2017.

Enrollment in Pediatric ACS NSQIP®

The Division of Pediatric Surgery recently enrolled in the pediatric version of The American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®). Participation in the pediatric ACS NSQIP® will enable our surgeons to track surgical outcomes data and measure it against a national baseline to identify areas of improvement, and will also allow our team to share process improvement ideas and best practices with other institutions.

The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP)

The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) aims to improve the value of care delivered by helping endocrine surgeons make informed decisions quickly and facilitate continuous improvement. The program was recently approved by the Centers for Medicare and Medicaid Services (CMS) as a Qualified Clinical Data Registry for the 2017 reporting year, which captures and analyzes data that are clinically relevant for endocrine surgeons, thus allowing physicians to understand and adjust their 2017 performance to improve patient outcomes and optimize future reimbursements under the CMS Quality Payment Program. 

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program® (MBSAQIP®)

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program® (MBSAQIP®) accredits bariatric surgery centers in the United States and Canada in accordance with nationally recognized bariatric surgical standards. The MBSAQIP® aims to provide continuous quality improvement of bariatric patient care, including improved morbidity and mortality.

The MBSAQIP® has been implemented system-wide. Three bariatric programs within the Mount Sinai Health System have received accreditation from the MBSAQIP® – three of only 64 sites in New York State.   This accreditation allows the programs to compare their risk-adjusted surgical outcomes to other participating MSBAQIP® centers and make changes where needed, based on national comparison data. The bariatric surgery program at Mount Sinai Beth Israel (MSBI) recently received accreditation as a Comprehensive Center from the MBSAQIP® in September 2016. The bariatric surgery program at Mount Sinai St. Luke’s (MSSL) received its initial accreditation as a Comprehensive Center from the MBSAQIP® in October 2012. The Mount Sinai Hospital’s (MSH) bariatric program received its initial accreditation from the MBSAQIP® as a Comprehensive Center with Adolescent Certification in July 2011.

The MSBI, MSH, and MSSL MBSAQIP® Committees meet to review the quality metrics every quarter and develop process improvement strategies accordingly.

The Mount Sinai Health System Bariatric Collaborative

The Mount Sinai Health System Bariatric Collaborative allows three of our hospital sites to share quality initiatives and best practices. The Collaborative meets bi-annually to discuss their respective case volume and quality/process measures. The multidisciplinary team compare their risk-adjusted surgical outcomes to other participating Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®) centers.

The Vascular Quality Initiative® (VQI®)

The Vascular Quality Initiative® (VQI®) aims to improve the quality of vascular health care in participating centers. The VQI® is administered by the Society for Vascular Surgery Patient Safety Organization (SVS PSO), which partners with M2S to provide a secure database for data collection and analysis. Participation in the VQI® enables our surgeons to compare major outcomes with aggregate data from participating centers. The VQI® also involves a network of regional quality groups that aim to reduce costs through participation in quality projects. The VQI® is now a system-wide initiative –MSBI, MSH, and MSSL all participate in the VQI®.