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The Mount Sinai Hospital is a 1,139-bed tertiary and coronary care teaching facility affiliated with the Icahn School of Medicine at Mount Sinai and part of the Mount Sinai Health System in New York City. Mount Sinai Heart is a 170 bed “hospital within a hospital” that offers cardiac surgery, interventional cardiology, electrophysiology, and a large heart failure program for patients.

We spoke with:

  • Beth Oliver, Chief Nurse Executive and the Sr VP of Cardiac Services for the Mount Sinai Health System
  • Carmen Franco, Director of Quality for Mount Sinai Heart
  • Elyisha Dawson, Sr Director of Operations for Cardiac Services and System Nursing
,,It was encouraging to see the reviewer engage with staff when they came onto the units, eliciting questions and providing real time feedback. It really was more of an educational process as opposed to just pointing out the gaps.,,

Carmen Franco - Director of Quality - Mount Sinai Heart

Q. What led your organization to seek Comprehensive Cardiac Center Certification from ÐÇ¿Õ´«Ã½?


Oliver: We are always striving to be a high reliability organization. We want to provide an excellent patient experience and be a destination facility that delivers high quality care and outcomes. The decision was clinically and operationally driven with the complete support of our physician and hospital leadership.

Q. What kind of preparation did you do for the survey?

Dawson: We did a lot of early communication across all our collaborating departments. It was exciting to see everyone committed to this shared goal of achieving this prestigious certification, bringing teams together across departments and disciplines.
Oliver: This is a large institution, but we were able to get everybody to work together. We went through the gap analysis and action plan going standard by standard, identifying owners and creating interdisciplinary teams to increase collaboration across all our domains. It was a lot of work, but our nurses, our advanced practice providers and our physician leads all came together to align on our performance improvement initiatives. Everybody was eager to participate.
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Franco: Breaking up tasks into smaller projects helped the process. We organized ourselves into small groups, which allowed us to focus on more manageable components of each domain.
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Oliver: One of the unique things that we did was enable people who already worked side-by-side to do so even more closely. Doctors and nurses knew each other, of course, but the certification process helped to create a more social aspect. I think that really helped.

For example, Mount Sinai has a large and prestigious cardiac surgery program that historically, has functioned more independently. Through this certification process, we were able to better align all of our domains, including cardiac surgery, interventional, electrophysiology, the emergency room and other supporting departments. Through this shared goal, it really made us feel like we were all on the same team.

Q. What was it like working with ÐÇ¿Õ´«Ã½ throughout the process?


Franco: Because it was a new certification we had a lot of questions. We were able to call and ask anything about the standards, which helped develop a really good rapport before starting the actual survey process. It was very beneficial to have this type of relationship. It made it easier for us and gave us peace of mind that we were able to speak to someone at ÐÇ¿Õ´«Ã½ to clarify any questions that came up along the way.

When the reviewers conducted our onsite visit, they were extremely positive. It was encouraging to see the reviewer engage with staff when they came onto the units, eliciting questions and providing real time feedback. It really was more of an educational process as opposed to just pointing out the gaps. They made it very clear that if someone didn’t understand they should speak up and ask for clarification which made it a great learning experience for everyone.

Q. What improvements were a result of your survey preparation process?

Franco: We definitely saw improved teamwork across all our disciplines, with everyone committed to a shared goal. Upon achieving certification, we continued to build upon our quality initiatives, implementing the feedback we received from the reviewers. By doing so, our quality review process has become more collaborative and robust allowing us to meet our performance targets.
Oliver: Through this process, our front line staff became more engaged in continuous process improvement. We engaged teams by domain, focusing on specific areas and quality metrics relevant to those units or departments. By doing so, staff have become more aware of their impact on the quality metrics and together we are on this high reliability journey with our data and outcomes.
A female doctor holds the hand of an elderly female patient.
A close up photo of EKG tape.
A large group of doctors and nurses stand outside a medical building.

Q. What has the impact of certification been on your community?

Dawson: There’s a shared pride because everyone worked so hard to achieve this. We collaborated with our marketing department to update patient facing marketing materials to share that we were the first hospital on the East Coast to achieve this certification and that it represents our commitment to excellence in cardiac patient care.

Oliver: We are extremely proud of the team’s accomplishment in receiving this prestigious certification. We are also proud to share our certification journey with other institutions. In fact, we were at a conference and nurses from a hospital in New Jersey asked us many questions about the process. How did we do it, how did we get started, etc.? We were more than willing to share our experience and help others achieve their goals, similar to how the team from St. Luke’s Hospital in Kansas City helped us as we embarked on our Comprehensive Cardiac Center journey.

,,Upon achieving certification, we continued to build upon our quality initiatives, implementing the feedback we received from the reviewers. By doing so, our quality review process has become more collaborative and robust allowing us to meet our performance targets.,,

Carmen Franco - Director of Quality - Mount Sinai Heart

Q. What would you say to organizations considering Comprehensive Cardiac Center certification?

Dawson: When we started this journey, we engaged multidisciplinary team members early on in the process and held a kickoff meeting where we provided more information about the benefits and process of certification. This really helped us create some momentum and excitement amongst the various teams. Additionally, we shared information about this certification with our front line teams in both our inpatient and outpatient areas. Then, of course, we went through the gap analysis process and developed an action plan by standard, identifying owners and creating interdisciplinary teams to increase collaboration across all our domains.

Oliver: Get leadership buy-in. Our President was our biggest cheerleader, and he was visibly supportive.

There’s really no downside to it. Certification is a good thing for everybody. It increases morale, focusing on quality and working together as a team on something that we could all achieve together. You can do it. You can improve quality, enhance staff performance, satisfaction and engagement.

Discover more about Joint Commission Comprehensive Cardiac Center Certification

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