Office of Quality and Patient Safety

The Department of Medicine's Office of Quality and Patient Safety is committed to objective, systematic, and fair processes for monitoring quality, safety and appropriateness of services in order to achieve excellence in patient care throughout the Mount Sinai Health System.

Our approach is to plan, assess, measure, and implement performance improvement in the systems and processes which affect the quality of care and services we provide. Membership of the Department's Quality Improvement Committee includes representation from all of the primary care and subspecialty divisions.

In addition to focusing on the key priority quality and patient safety indicators for the Mount Sinai Health System, each of the divisions within the Department of Medicine at The Mount Sinai Hospital, Mount Sinai Beth Israel and Mount Sinai St. Luke's and Mount Sinai West select at least three meaningful quality projects annually. These are outlined in the department's Clinical Quality and Patient Safety Performance Improvement Plan.

The divisions are assisted in selecting appropriate metrics for each goal, defining the processes to be measured, monitoring the performance indicators on a monthly basis and reporting successes and challenges to their local Quality Improvement Committee biannually.

The department also offers quality and performance improvement training for medical students and residents that provide an enhanced quality curriculum, an opportunity to sit in on senior level administrative meetings, discuss policy issues and review administrative data to determine areas where improvement is needed. During the monthly Resident Quality Improvement Committee meetings trainees review cases where there are opportunities for improvement. Working in small groups, a modified fishbone diagram or process map is utilized to perform root causes analyses. These findings are brought to the larger workgroup, which brainstorms corrective action plans to prevent future harm. Trainees also have the opportunity to work on quality projects utilizing hospital data to improve clinical practice and immediately impact care. Residents in the Health Care Leadership Track are given educational and informative lectures to enhance their skills to improve hospital systems and processes.

The department's High Value Care Committees seek to help physicians provide the best possible care while simultaneously reducing unnecessary health care costs to the hospital and healthcare system. The committees implement a quality improvement curriculum that is centered on overuse including case presentations during the resident quality conference. The Student High Value Care Committee is an initiative at the Icahn School of Medicine in which medical students form collaborative teams to identify points of low value care and implement novel interventions.

Robust Mortality and Morbidity Committees at each of the hospitals in the system meet monthly to discuss cases of patients who have died in the hospital or where there was a serious adverse event that occurred. Prior to the meeting the case is reviewed by a faculty member, who ascertains whether the case does or does not meet the standard of care and where there are opportunities for improvement. In addition to Department of Medicine faculty and residents, membership includes hospital risk management, quality, and nursing.