Annual Perioperative Report 2025 Proprietary and Confidential
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Annual Perioperative Report 2025 Welcome and Executive Message ..............................................................................................................................4 Message from Amanda J. Rhee, MD, MS ................................................................................................................................ 4 Message from David Reich, MD .................................................................................................................................................. 5 Message from Brendan Carr, MD, MS, MA ............................................................................................................................. 6 Message from Evan Flatow, MD .................................................................................................................................................. 6 Clinical and Operational Landscape ..........................................................................................................................7 Vision and Mission ............................................................................................................................................................................. 8 Nine Facilities ....................................................................................................................................................................................... 9 Meet the Team .................................................................................................................................................................11 Perioperative Services Leadership Team..............................................................................................................................12 Communication Strategy ..............................................................................................................................................................14 Dashboard Development, Data Transparency, and Process Improvement ......................................................... 16 Key Initiatives ................................................................................................................................................................. 17 Operating Room and Endoscopy Efficiency Improvements ....................................................................................... 18 Main Efficiency Metrics ..............................................................................................................................................................19 Leveraging Technology to Support Operating Room and Endoscopy Efficiency ..........................................32 Scheduling ......................................................................................................................................................................................... 36 Clarium Preference Cards .......................................................................................................................................................36 Procedure Dictionary Conversion ........................................................................................................................................36 OR Marketplace ............................................................................................................................................................................ 37 Safety Quality Experience .......................................................................................................................................................... 39 Summary of Standardized Policies from SCOPE Committee ..................................................................................39 Documentation Compliance Targets ..................................................................................................................................... 43 Sterile Processing Department ................................................................................................................................................ 45 Patient Experience ......................................................................................................................................................................... 46 Surgical Patient Experience ....................................................................................................................................................46 Epic My Next Steps .....................................................................................................................................................................50
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Perioperative Value Analysis ..................................................................................................................................................... 50 Supply Management for Perioperative Services ............................................................................................................ 51 Supply Management: Anesthesia Technology Operations: Conversions and Logistics .............................. 51 System Healthcare Asset and Redistribution Exchange (SHARE)........................................................................52 Endoscopy ......................................................................................................................................................................................... 53 Staff Experience.............................................................................................................................................................................. 54 Your Voice Counts Survey ........................................................................................................................................................54 Best and Most Improved Hospital in System Operating Room Efficiency .......................................................... 57 Looking Ahead ...............................................................................................................................................................61 Strategic Goals and Objectives for Fiscal Year 2026 .................................................................................................... 62 Appendix ........................................................................................................................................................................ 63 Perioperative Services System Leadership Team .......................................................................................................... 64 Administrative Operations .......................................................................................................................................................64 Clinical Alignment ........................................................................................................................................................................65 Clinical Operations ......................................................................................................................................................................65 Information Technology ............................................................................................................................................................66 Nursing..............................................................................................................................................................................................66 Transformation and Process Improvement ......................................................................................................................66 Perioperative Services Hospital Leadership Team ..........................................................................................................67 Acknowledgement of Partners ................................................................................................................................................. 68 Contact Info for Feedback or Engagement ........................................................................................................................ 69
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Mount Sinai Annual Perioperative Report 2025
Partnering for the Best Procedural Care 3
Message from Amanda J. Rhee, MD, MS Vice President of Perioperative and Procedural Services, Mount Sinai Health System
It has been my privilege to step into this role to serve our patients, staff, and the Mount Sinai Health System to support procedural care in the operating rooms and endoscopy suites. Our vision is rooted in partnership, which I believe is the key to how we have been able to see rapid improvements this year, some of which we will share in this report, and how we will continue to work together to create the best experience we can for our patients and staff.
time, reducing cancellations, improving turnaround times, and improving block and prime-time asset utilization compared to last year. Our value analysis process now includes clinical perspectives from surgical and anesthesiology specialties, as well as a more complete financial analysis that allows us to understand both cost and potential for investment and growth. This systemwide focus has allowed us to better manage supplies, capital equipment, and implants for improved availability and less waste. We are leveraging technology and expanding applications and responsibly leaning into artificial intelligence to better analyze, predict, and understand how to best manage each day and enhance our work. I hope you enjoy reading this report to explore what we accomplished in 2025 and how we plan to continue to expand on this work. Thank you all for your partnerships. We recognize our success is from teamwork and that there is much more to do. I look forward to continuing this journey with you.
We are working to further connect our hospitals around the Health System to share expertise and resources. This has helped us better understand what our teams need, including hearing ideas and best practices that the entire Health System can benefit from. We have also increased our pool of resources by functioning as a health system instead of individual hospitals or entities. We have begun to see improvements in operating room and endoscopy efficiency, including ensuring we start cases on
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Mount Sinai Annual Perioperative Report 2025
Welcome and Executive Message
Message from David Reich, MD Chief Clinical Officer, Mount Sinai Health System President, The Mount Sinai Hospital
The growth in perioperative and procedural volume, quality, and efficiency over 2025 has been a remarkable achievement for One Mount Sinai. Under the leadership of Amanda Rhee, MD, MS, the new Vice President of Perioperative and Procedural Services, Mount Sinai Health System, we have seen an energetic and highly effective team-based approach to data-driven management, transparency in operational, clinical, and quality dashboards, and a refreshing
re-dedication of our staff to patient experience. Integrating perioperative and procedural services across our vast Health System is not a trivial undertaking, and the hard work in establishing the data and operational infrastructure in this first year of Dr. Rhee’s tenure has positioned us for further improvements in 2026 and beyond. Most importantly, we owe these improvements to our dedicated perioperative and procedural teams that place patient care at the core of their efforts.
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Message from Brendan Carr, MD, MS, MA
6
Message from Evan Flatow, MD
Chief Executive Officer, Mount Sinai Health System
Executive Vice President for Clinical Affairs, Mount Sinai Health System Dean for Clinical Affairs, Icahn School of Medicine at Mount Sinai
The operating rooms and endoscopy suites are seeing improvements with fresh perspectives from Dr. Rhee, and a new systemwide Perioperative Leadership Team that builds on an existing strong foundation of work. Creating safe and efficient procedures is an essential part of the Health System’s mission, and this year is a testament to how effective partnerships can lead to success by leaning into the One Mount Sinai framework. Thank you to the many who are working together to improve procedural care throughout the Health System. I look forward to a bright future and what the coming years will bring.
As a surgeon, I am especially proud of the great progress being made in our perioperative program. In addition to new and renovated procedural spaces and sterile processing facilities, Dr. Rhee and her team have partnered with our surgical and anesthesiology faculty, nurses, and other staff to develop data dashboards, better processes for efficiency, and other workflow improvements. Our world-renowned surgeons continue to develop innovative procedures and minimally invasive approaches. Congratulations to the entire perioperative team for the great achievements documented in this report.
Mount Sinai Annual Perioperative Report 2025
Welcome and Executive Message
Clinical and Operational Landscape 7
Vision and Mission
Vision Partnering to Create Procedural Excellence
Mission Partner to create the optimization strategy for Health System alignment on procedural safety, quality, data, equity, innovation, efficiency, and experience for patients and staff.
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Nine Facilities
The Mount Sinai Health System’s Perioperative and Procedural Services department supports a vast and complex network of surgical and procedural care, encompassing seven hospitals and two ambulatory surgical centers. With 145 main operating rooms and 20 endoscopy suites, the Health System delivers care to more than 120,000 patients annually. This large-scale operation is made possible by a dedicated team of more than 2,000 perioperative staff, working across various specialties to ensure safe, efficient, and compassionate care throughout each patient’s procedural journey.
M o un untt S Sii nai M o rni nin n gs gsii d e The M Mo o un untt S Sii nai H o s p it ita al
M o un untt S Sii nai Wesst We
M o un untt S Sii nai Q ue ueen enss
N ew Yo Yo rk Ey Ey e and E Ea a r In Inffi rma marr y of M Mo o un untt S Sii nai
Th e Bl B l avatn i k Fa Fa m i ly Chel s e a M Chels Me e dic dica al C Cen entter at M Mo o un untt S Sii nai M o un untt S Sii nai U n i on S Sq q uar uare e
M o un untt S Sii nai S o uth Na Nass sa sau u
M o un untt S Sii nai Q ue ueen enss
Source: Map generated with Google Maps. Hospital labels added.
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Nine Facilities (continued)
10
Facility
# ORs
2025 OR Case Volume
# Endoscopy Rooms
2025 Endoscopy Case Volume
Mount Sinai Brooklyn
5
2,942
2
1,721
The Mount Sinai Hospital
51
30,007
6
10,381
Mount Sinai Morningside
14
8,865
3
5,207
Mount Sinai Queens
6
5,407
2
1,760
Mount Sinai South Nassau
17
10,514
4
5,333
Mount Sinai West
22
15,311
3
5,567
New York Eye and Ear Infirma y of Mount Sinai
19
11,688
–
–
Inpatient Facilities Subtotal
134
84,734
20
29,969
Mount Sinai Chelsea
2
1,701
–
–
Mount Sinai Union Square
6
5,576
–
–
Ambulatory Facilities Subtotal
8
7,277
–
–
Mount Sinai Health System Total
142
92,011
20
29,969
Mount Sinai Annual Perioperative Report 2025
Clinical and Operational Landscape
Meet the Team 11
Perioperative Services Leadership Team
Please Meet Our Perioperative Leaders These leaders include both a strong foundation of seasoned experts as well as new leadership both at the hospital and system levels, who bring a fresh perspective to build upon and evolve existing workflows. Please meet the team below. Their pictures and titles are available in the appendix. Feel free to reach out to them with your questions and ideas. Perioperative Services System Leadership Team* We have a new Perioperative Services System Leadership Team, which works with teams across the Health System to align the work, learn from each other, and build enterprise solutions.
Administrative Operations
Clinical Alignment
Clinical Operations
Information Technology
Nursing
Transformation and Process Improvement
Michael Arabia, MHA
Neha Malhotra, MD Medical Director, Procedural Quality
Fran Maura Carpo, RN, MSN, CNOR
Jeanne Chang, RN, MS, CNOR
Nicole Ng, RN, MSN, CNOR
Astrid Pineda, MPA
Director of Logistics
Tissue Compliance Officer
Procedural Clinical Technology Director
Senior Director of Perioperative Nursing Practice
William DeLuca, BBA, CRCST, CHL, CIS
Suzie Mei Kuan Xie, PA-C, MBA
Ricardo A. Lazala, MD
Abbe Craven, MD
Abigail Pfister
Senior Director, Sterile Processing Department
Clinical Operations Senior Director
Vice Chair and Senior Director, Cardiovascular Surgery Clinical Services
Director of Clinical Informatics, Digital Technology Partners
Director, Strategic Initiatives and Operational Excellence
Maximilian Julian, MHSA
Jason Sangyoon Shin, DO
Joseph Lewis, CCP, LP
Andrey Sergeev
Director of Endoscopy Operations
Medical Director
Chief of Cardiovascular Perfusion
Procedural Data and Dashboards Manager
Jonathan Scutchfield, MBA
Erin Gabriel, MD
(Administrative Report)
Director of Financial Planning and Analysis
Medical Advisor, Perioperative Medicine Hospital Medicine
Joshua Villar
Taylor White, MD
Senior Director, Anesthesiology Technology
Medical Advisor, Perioperative Medicine Anesthesiology
* Note: Each of our team members is part of Perioperative and Procedural Services, Mount Sinai Health System. 12
Mount Sinai Annual Perioperative Report 2025
Meet the Team
Project Manager
Perioperative Services Hospital Leadership Team Our perioperative hospital nursing leaders are the bedrock of daily operations and a resource of expertise for creating sustained improvements. These leaders work with our Health System’s Perioperative Services System Team to build workflow improvements and future-state endeavors.
Amanda Rhee, MD, MS Vice President, MSHS Perioperative and Procedural Services
Beth Oliver, DNP, RN, FAAN Chief Nurse Executive, MSHS Chief Nursing Officer Per Hospital
Venetia WalkerCowan, DNP, MBA, RN, NEA-BC, CDXP, CNOR, CSSM, CNAMB
Maude Dodier, MSN, RN
Leah Borenstein, MPA, RN, CNOR
Michael Johnson, MHA, RN, CNOR
Minimol Shebeen, RN
Director, MSQ
Vice President, MSW/MSM
Acting Vice President, MSH
Director, NYEE
Director, MSB
Jane Bautista Director, MS Downtown Ambulatory Surgery
Nicole Ng, MSN, RN, CNOR Senior Director, MSSN
Yelena Bortnovskaya MSN, RN Senior Director, MSM Perioperative Services Inga Meinikova DNP, FNP-C, RN Senior Director, MSW Perioperative Services
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Communication Strategy
The communication strategy for the Mount Sinai Health System’s Perioperative and Procedural Services department is designed to ensure transparency, alignment, and collaboration across all teams that work in or support procedural care. The OR and Procedural Bulletin provides regular systemwide updates on workflow enhancements, safety initiatives, policy changes, and other operational developments. These concise communications keep perioperative staff informed and connected to organizational priorities, supporting consistency and awareness across all campuses.
A cornerstone of engagement with operating room and endoscopy teams is the annual OR and Procedural Safety Summit, a mandatory, systemwide live event that unites all staff working in and supporting the main operating rooms and endoscopy suites. The summit delivers where we are, our trajectory, educational content, and reinforces Mount Sinai’s commitment to patient and staff safety, quality, and operational excellence, and strengthens engagement and alignment across perioperative teams.
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The PreopWebApp is a comprehensive, web-based resource designed to support staff across all phases of perioperative care. The application provides workflow guidance, Epic tip sheets, OR- and procedural-specific policies and protocols, and systemwide announcements.
www.mountsinai.org/preop
The annual Spring Perioperative Town Hall is a systemwide event that brings together staff from across Perioperative and Procedural Services to review accomplishments, highlight strategic goals, and share updates on quality, safety, and operational performance early in the year. Like the safety summit, this event reinforces transparency and a shared purpose across teams and sites. Together, these communication channels strengthen engagement, promote consistency, and foster a unified perioperative community dedicated to continuous improvement and exceptional patient care.
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Dashboard Development, Data Transparency, and Process Improvement Process improvement methodology is essential to operational work and includes a data-driven approach. We use dashboards and standardized metrics, jointly created by chairs, perioperative leaders, and executives, to understand where we are and to drive improvements. Data are shared with teams in a number of ways, including Health System and Hospital OR and Endoscopy Committee meetings and working groups, departmental meetings and daily huddles, the annual OR and Procedural Safety Summit, executive reports, and this annual report. With Mount Sinai South Nassau’s new Epic launch and another Epic launch scheduled at New York Eye and Ear Infirmary of Mount Sinai to follow, we will soon have all operative locations on Epic with standardized metrics. Below is the suite of dashboards that serve as the single source of knowledge for ensuring we are all aligned in how we understand our current performance and the efficacy of our improvements. You will see examples of these dashboards throughout this report.
Procedural Dashboard Landing Zone
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Procedural Executive
OR Efficiency
Overlapping Surgery
Procedural H&P Compliance
Brief OP Note Compliance
Full OP Note Compliance
Key Initiatives 17
Operating Room and Endoscopy Efficiency Improvements
The System Procedural Efficiency Committee (SPEC) is working to make operations run more smoothly and efficiently through initiatives aimed at improving workflow optimization, resource utilization, and patient throughput.
SPEC Vision Smarter Procedural Throughput
SPEC Mission Ensure optimal utilization of prime-time procedural hours by making procedural workflows more efficient.
Key metrics tracked on the dashboards described above include: • First Case On-Time Starts • Turn Around Time • Prime-Time Utilization • Case Cancellations • Block Utilization
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OR Efficiency Accomplishments Procedural Efficiency Dashboard, OR Efficiency Metrics, Through 12/31/25 Main OR MSB, MSH, MSM, MSQ, MSW
Target Reference Line Stretch System Reference Line Target Met Stretch System Target Met Below Target
OR Efficiency Key Outcomes (Comparing 2024 and 2025) First Case On-Time Starts
Case Cancellations
Service Block Utilization
OR Room Utilization
• 600 fewer hours delayed getting first cases started in 2025 compared to 2024
• 1,040 fewer cases canceled same day and day prior, compared to 2024
• 5,727 more block hours released in 2025 than in 2024
• Improved by 1 percent in 2025 (68%) compared to 2024 (67%)
Notes: Data through 12/31/2025. Excludes MSSN. 19
Operating Room and Endoscopy Efficiency Improvements (continued)
Procedural Efficiency Dashboard: Data and Interventions | OR Efficiency Metrics Full Year 2025 Original MSHS Targets – Target and System Stretch Main OR MSB, MSH, MSM, MSQ, MSW Full Year 2024
2025
Q2 ‘25
Q3 ‘25
Q4 ‘25
Full Year 2025
Metric (Main ORs)
MSHS
Target
System Stretch
MSHS
First Case On-Time Start (FCOT)
77%
≥ 80%
≥ 85%
83%
85%
85%
84%
84%
Turnover Time (TAT) - All Cases
44
≤45 m
≤ 40 m
43
43
43
43
43
Turnover Time (TAT) - % Cases ≤ 45 Min
53%
≥ 55%
≥ 60%
56%
56%
55%
57%
56%
Turnover Time (TAT) - % Cases ≤ 45 Min, with Cap
57%
≥ 60%
≥ 65%
59%
60%
58%
60%
59%
Case Cancellation - Same Day
8%
≤ 7%
≤ 6%
7%
6%
6%
6%
6%
Case Cancellation - Same Day + Day Prior
14%
≤ 12%
≤ 11%
12%
12%
12%
12%
12%
Case Length Accuracy +/- 20 min
32%
≥ 33%
> 35%
31%
31%
31%
30%
31%
OR Utilization
67%
≥ 70%
≥ 73%
70%
69%
68%
67%
68%
In Block Utilization
54%
≥ 55%
≥ 58%
57%
56%
59%
59%
58%
Target Met System Stretch Met Below Target
Notes: Data through 12/31/2025. Excludes MSSN.
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Q1 ‘25
OR Efficiency Metrics, 2024 vs. 2025 % Block Utilization Main OR MSB, MSH, MSM, MSQ, MSW
Block Utilization by Month (2024 vs. 2025) 100% 90
MSH OR Marketplace
System Block Policy
80 70 60
56%
58%
56%
55%
54%
55%
53%
53%
50 40
58% 56%
58%
59%
53%
53%
63% 56% 52%
56%
59%
61%
55%
54%
56%
46%
30 20 10 0 Jan
Feb
Mar
Apr
May
Jun 2024
Jul
Aug
Sep
Oct
Nov
Dec
2025
Notes: % Block Utilization – Service Block % Used (In Block). Data through 12/31/2025. Excludes MSSN.
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Operating Room and Endoscopy Efficiency Improvements (continued)
OR Efficiency Metrics, 2024 vs. 2025 % OR Utilization Main OR MSB, MSH, MSM, MSQ, MSW
Main OR Utilization by Month (2024 vs. 2025)
100%
MSHS System Block Policy Release Go Live 5/2025
90
NYC Transit Strike 5/16/25
80 70% 70 68%
71% 72%
69% 69%
60
68% 67%
71%
68%
70%
67%
MSH SPD Mechanical Shutdown 7/7/25
68%
65%
MSH OR Flood 8/7/25
66% 65%
69%
69%
68%
69%
69% 63% 68% 59%
CrowdStrike 7/19/2024
50 40 Jan
Feb
Mar
Apr
May
Jun 2024
Notes: Data through 12/31/2025. Excludes MSSN.
22
Jul
Aug 2025
Sep
Oct
Nov
Dec
First Case* Total Delayed Minutes Main OR MSB, MSH, MSM, MSQ, MSW
Total Delayed Hours by Month, First Cases (2024 vs. 2025)
250 200 200 158 131
150
120
110
135
134
120
106
150 115
112
100 91 50
82
97 67
74
96 70
75
Jun
Jul
90
98
89 61
0 Jan
Feb
Mar
Apr
May
2024
Aug
Sep
Oct
Nov
Dec
2025
1,591 hours delayed in 2024 vs. 991 hours delayed in 2025 = 600 fewer hours delayed in 2025 compared to 2024
Notes: FCOT – Total Delayed Hours. Data through 12/31/2025. Excludes MSSN. * “First Case” = First case of the day for a single surgeon.
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Operating Room and Endoscopy Efficiency Improvements (continued)
Case Cancellation Rate, Same Day and Next Day Main OR MSB, MSH, MSM, MSQ, MSW
Case Cancellation Rate, Same Day and Next Day (2024 vs. 2025) 16% 14 12
14% 13%
15%
13%
15% 13%
13%
13%
13%
12%
12%
12%
12%
Mar
Apr
May
Jun
13%
13%
13%
12%
12%
12%
12%
Jul
Aug
Sep
Oct
13%
13% 13%
11%
10 8 6 4 2 0 Jan
Feb
2024
Nov
2025
1,040 fewer cases canceled same day and next day in 2025, compared to 2024
Notes: Data through 12/31/2025. Excludes MSSN.
24
Dec
Turnaround Time Main OR MSB, MSH, MSM, MSQ, MSW
Average Percentage of Cases within Target (2024 vs. 2025) 100% 80 60 40
60%
60%
60%
59%
60%
59%
56%
57%
58%
58%
57%
57%
57%
56%
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
44
44
44
43
43
44
Jul
Aug
Sep
57%
57%
58%
55%
59%
58%
62%
56%
60%
58%
20 0 Oct
Nov
44
44
Dec
Average TAT by Month (2024 vs. 2025) 60
50
40
44
44
44
44
44
44
43
42
43
43
Feb
Mar
Apr
May
44
42
44
43
43 43
30
20 Jan
Jun 2024
Oct
Nov
Dec
2025
Notes: TAT – Average TAT + % of Cases within Target. Data through 12/31/2025. Excludes MSSN.
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Operating Room and Endoscopy Efficiency Improvements (continued)
Operating Room Block Management Policy Main OR MSB, MSH, MSM, MSQ, MSW
Released Block Hours, by Month (2024 vs. 2025) 16% 14 1498
12
1490
System Block Policy
10
MSH OR Marketplace
1287
959 8 777 6
502
971
821
747
691
555
4 180
217
Jan
Feb
304
268
Mar
Apr
366
706
757
426
372
697 549
538
180
2 0 May
Jun 2024
Jul
Aug
Sep
Oct
Nov
Dec
2025
5,063 block hours released in 2024 vs. 10,795 block hours released in 2025 = More than 5,700 additional block hours released in 2025 compared to 2024 (2x change)
Notes: Data through 12/31/2025. Excludes MSSN.
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Total Volume Showing Inpatient vs. Outpatient Cases Main OR MSB, MSQ, MSH, MSM, MSW
Procedural Volume (By Discharge Patient Volume) Total Volume: Inpatient + Outpatient 6K
4
2
0 1
2
3
4
5
6
7
Volume: Inpatient
8
9
10
11
12
Volume: Outpatient
3K
3K
2
2
1
1
0
0 1
2
3
4
5
6
7
8
9
10
11
12 2024
1
2
3
4
5
6
7
8
9
10
11
12
2025
Notes: Data through 12/31/2025. Excludes MSSN.
27
Operating Room and Endoscopy Efficiency Improvements (continued)
Main Efficiency Metrics Ambulatory Operating Rooms
OR Efficiency Accomplishments Procedural Efficiency Dashboard, Data Extraction Jan – Dec 2025 Ambulatory Operating Rooms: MSDUS, MSDC
Notes: Data through 12/31/2025.
28
Target Reference Line Stretch System Reference Line Target Met Stretch System Target Met Below Target
Procedural Efficiency Dashboard: Data and Interventions | OR Efficiency Metrics Full Year 2025 Original MSHS Targets – Target and System Stretch Ambulatory ORs: MSDC and MSDUS Full Year 2024
2025
Q2 ‘25
Q3 ‘25
Q4 ‘25
Full Year 2025
MSHS
Target
System Stretch
MSHS
First Case On-Time Start (FCOT)
80%
≥ 80%
≥ 88%
83%
88%
86%
85%
85%
Turnover Time (TAT) - All Cases
35
≤ 30 m
≤ 27 m
29
29
33
29
29
Case Cancellation - Same Day
4%
≤ 5%
≤ 4%
3%
3%
3%
3%
3%
Case Cancellation - Same Day + Prior
11%
≤ 7%
≤ 6%
9%
8%
8%
9%
8%
OR Utilization
67%
≥ 70%
≥ 73%
66%
65%
62%
59%
63%
In Block Utilization
53%
≥ 60%
≥ 63%
57%
58%
56%
54%
54%
Metric (Ambulatory OR)
Q1 ‘25
Target Met System Stretch Met Below Target
Notes: Data through 12/31/2025.
29
Operating Room and Endoscopy Efficiency Improvements (continued)
Main Efficiency Metrics Endoscopy
Endoscopy Efficiency Accomplishments Procedural Efficiency Dashboard, Data Extraction Jan – Dec 2025 Endoscopy MSB, MSH, MSM, MSQ, MSW
Notes: Data through 12/31/2025.
30
Target Reference Line Stretch System Reference Line Target Met Stretch System Target Met Below Target
Procedural Efficiency Dashboard: Data and Interventions | OR Efficiency Metrics Full Year 2025 Original MSHS Targets – Target and System Stretch Endoscopy Full Year 2024
2025
Q2 ‘25
Q3 ‘25
Q4 ‘25
Full Year 2025
Metric (Endo)
MSHS
Target
System Stretch
MSHS
First Case On-Time Start (FCOT)
61%
≥ 70%
≥ 75%
62%
62%
67%
67%
67%
Turnover Time (TAT) - All Cases
25
≤ 21 m
≤ 18 m
24
24
28
24
24
Case Cancellation - Same Day
15%
≤ 14%
≤ 11%
13%
13%
13%
14%
14%
Case Cancellation - Same Day + Prior
18%
≤ 15%
≤ 12%
17%
17%
15%
16%
16%
OR Utilization
74%
≥ 75%
≥ 78%
76%
78%
74%
75%
75%
In Block Utilization
55%
≥ 55%
≥ 58%
57%
58%
56%
52%
56%
Q1 ‘25
Target Met System Stretch Met Below Target
Notes: Data through 12/31/2025
31
Operating Room and Endoscopy Efficiency Improvements (continued)
Leveraging Technology to Support Operating Room and Endoscopy Efficiency
Overview Abbe Craven, MD, Assistant Professor in Ophthalmology and Director in Clinical Informatics, and Jeanne Chang, MS, RN, CNOR, serve as co-chairs of the System Committee for OR/Procedural Upgrades and Technology (SCOUT). This committee is responsible for the creation, alignment, and strategic implementation of information technology initiatives that pertain to procedures. You will see examples of this collaborative work below and throughout this report.
SCOUT Vision Leveraging Information Technology for Better Procedural Care
SCOUT Mission Align and centralize the strategy for leveraging information technology to optimize procedures in the main operating rooms and major procedural locations.
Key Initiatives This Year Epic Operating Room Readiness Status Boards were fully implemented across all Mount Sinai Epic sites as of late July 2025. The readiness boards are intended to help support and achieve several institutional goals, including reduced case delays and turnover times and improved history and physical documentation to meet regulatory requirements. The boards improve communication by providing transparency in clinical team readiness and reducing phone calls between clinical teams.
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MSH Wave I
MSH Wave II
MSW and MSM
MSB
MSQ
Sep. 12, 2024
May 6, 2025
June 24, 2025
July 1, 2025
July 22, 2025
All Epic Main OR Implementation
Below are our compliance data for The Mount Sinai Hospital, our first readiness board site, which has seen an upward trend in several readiness areas.
Prior to Patient in OR Suite MSH Wave I September 12, 2024
MSH Wave II May 6, 2025
100% 90
90% target
80
Compliance
70 60 50 40 30 20 10 0 202301
202304
202307
202310
202401
202404
202407
202410
202501
202504
202507
202510
Month Anesthesia Ready 97%
Room Ready 96%
H&P (Fully) Complete 92%
Pre-Procedure Complete 85% – SDA + Ambulatory Cases 98%
33
Operating Room and Endoscopy Efficiency Improvements (continued)
The Epic OR Marketplace is a tool that allows block owners or their appointed designees to release blocks and requests for operating room time, all within Epic. We partnered with Epic in their Level Up program, where they helped support the implementation at The Mount Sinai Hospital in early September 2025 and later that month to Mount Sinai Brooklyn, Mount Sinai Morningside, Mount Sinai Queens, and Mount Sinai West. OR Marketplace next steps that will launch in early 2026 include: • Expanding to voluntary providers • Expanding to additional facilities and locations • Providing mobile access to these tools using Haiku
Release block time directly in Epic easily and ahead of 21-day voluntary release window • Benefits block utilization Surgeons can shop for and request additional time using Epic tools
Marketplace Future Enhancements • Expansion to voluntary surgeons • Expansion to additional Epic sites • Haiku functionality • And much more!
34
MSH Go Live
MSM/MSW/MSB/MSQ Go Live
Sep. 8, 2025
Sep. 22, 2025
Oct. 2025 398 hours
Nov. 2025 MSHS OR Time 564 Requested via hours Marketplace Early 2026
System Optime Informatics Committee (SOIC) is a sub-committee under SCOUT and includes nursing and scheduling leadership throughout our Epic sites. SOIC ensures Epic Optime optimizations and solutions serve operational workflows across the Health System with consideration to industry best practices and align with regulatory guidelines.
SOIC Mission Enhancing the patient experience by optimizing the use of technological solutions in perioperative nursing and scheduling.
Key Projects in 2025 • PreOp Nursing navigator standardization – Unified and standardized preop nursing navigators to streamline documentation and drive greater efficiency in preparing patients for the next phase of their care • PreOp to OR situation, background, assessment, recommendation (SBAR) for Nursing • Enhanced the SBAR to better support phase‑of‑care handoffs and streamline communication by consolidating key information and minimizing the need to click through multiple sections • Lines, Drains, and Airways (LDA) avatar for dressings (upcoming Go Live Q2 2026) for Nursing intraop documentation Resolves several limitations in current surgical site dressing documentation and ensures continuity of care documentation during the patient’s stay.
35
Scheduling
Clarium Preference Cards Launching in 2026, Clarium Preference Card Optimizer is a preference card tool that provides AI-powered insights and some automation assistance in preference card management. The tool features a robotic process automation integration with Epic to automatically implement any evidence-based recommendations for preference card updates—removing the need for manual entries. This process will better ensure that preference cards remain updated, standardized, and optimized. This will improve financial stewardship and reduce waste.
Procedure Dictionary Conversion Coming this spring, the Mount Sinai Health System Epic Procedure Dictionary will be restructured to evaluate cases as procedures instead of individual Current Procedural Terminology (CPT) codes or clusters of CPT codes. Instead, we will use unified, clinically clear procedure names for each case, attaching CPT codes to the procedures to retain use for authorizations and billing. Identified impacts of the new Epic Procedure Dictionary: • Clinically and patient-friendly procedure names • Fewer preference cards linked to a case means fewer preference cards to manage per case, which leads to better accuracy, ensuring supplies needed for a case are present • Less ambiguity as to which procedure to choose • Expected improvement in case length accuracy, as the procedure will not be evaluated based on a cumulation of individual CPT codes. This leads to more accurate and predictable scheduling
36
OR Marketplace OR Marketplace (ORMP) isn’t just a place to shop for and release time. The tool automatically sends notifications to block owners if their upcoming block time is projected to be underutilized. These notifications are intended to prompt block owners to submit cases or release time, allowing as many surgeons as possible to have access to unused time for their patients. As users are adopting the tool, we have seen significant increases in released time as shown in the graph below.
Block Minutes Released by Users Who Have Read ORMP Reminder 2025 30K 24000
Block Minutes Released
25 20 15 9000
10
4200
5 0
9000
0
480 480 MSB
600
1200 1800 MSH
1200 1680
1200 MSM
2400
MSQ
3600
MSW
Marketplace Location October
November
December
During our initial launch of OR Marketplace, users were requesting time without attaching cases and allowing their held time to expire by not filling their requested time with cases. As users continue to familiarize themselves with the tool, more held time is being utilized—in some cases, five times as much. This means better access for surgeons, so their patients can receive the care they need.
37
Scheduling (continued)
Held OR Time Filled by Requestor 2025 70%
66
60
Held Time Utilized
50 40 33 30
25
20
22
16 11
10 0
0
0 MSB
0
5
2
0 MSH
0
MSM
0
0 MSQ
Marketplace Location October
38
November
December
MSW
Safety Quality Experience
Summary of Standardized Policies from SCOPE Committee System Clinical Operations for Procedures (SCOPE) Committee: Responsible for creation and alignment of standardized clinical best practices, policy, documentation, quality, equity, safety, and experience for patients and staff. SCOPE Leadership • Astrid Pineda, MPA, Project Manager, Perioperative and Procedural Services, Mount Sinai Health System • Sangyoon Jason Shin, DO, Medical Director, Perioperative Medicine, Perioperative and Procedural Services, Mount Sinai Health System • Abbe Craven, MD, Director in Clinical Informatics, Digital Technology Partners and Perioperative and Procedural Services, Mount Sinai Health System • Jeanne Chang, MS, RN, CNOR, Procedural Clinical Technology Director, Perioperative and Procedural Services, Mount Sinai Health System • Amanda Rhee, MD, MS, System VP, Perioperative and Procedural Services, Mount Sinai Health System System Policy Management • Nicole Ng, RN, MSN, CNOR, Senior Director, Perioperative Nursing Practice, Perioperative and Procedural Services, Mount Sinai Health System, Senior Director of Perioperative Services, Mount Sinai South Nassau System Procedural Quality • Neha Malhotra, MD, FACS, FAAP, Medical Director for Procedural Quality, Perioperative and Procedural Services, Mount Sinai Health System
39
Safety Quality Experience (continued)
The committee creates and maintains a range of policies and procedures, including but not limited to the Mount Sinai Health System: • Cell Saver • Contamination of Autologous Tissue or Allografts During a Procedure • Escort/Companion After Sedation • Informed Consent • Medical Device Vendor Representative • Operating Room Block Management • Overlapping Surgical Staffing of More Than One Operating Room • Pre-Procedure Testing and Medication Management Guidelines • Sedation/Analgesia Policy by Non-Anesthesia Team Members While Performing Procedures • Surgical and Procedural Attire • Surgical Smoke Safety • Universal Protocol • Venous Central and Peripheral Line The policies are available through PolicyTech and the PreopWebApp at www.mountsinai.org/preop.
40
Latest 2025 Updates Mount Sinai Health System Escort/Companion After Sedation The Mount Sinai Health System has updated its Escort/Companion After Sedation Policy to enhance patient experience and ensure safe post-procedure discharge. Patients undergoing ambulatory surgery or ambulatory major procedures are required to have a prearranged escort. Updates include clarified definitions of “escort,” guidance for documenting escorts and managing patients who arrive without one, and the addition of a transportation contact for Mount Sinai South Nassau. These changes support consistent and safe discharge practices across the Health System. Mount Sinai Health System Overlapping Surgical Staffing or More Than One Operating Room An overlapping surgery workflow allows us to serve more patients and increase access to the specialized care Mount Sinai has to offer. We continue our work to make sure our surgeons are delivering safe, world-class surgery and that our patients are informed about overlapping surgery practices, if applicable. Our strong commitment to safety and excellence, our transparency, and our dedication to documentation enable us to create more timely access to surgery for our patients and community. Mount Sinai Health System Pre-Procedure Testing and Medication Management Guidelines Incorporating the latest updates from the 2024 American College of Cardiology/ American Heart Association Perioperative Guidelines, we have updated our Health System protocols for preoperative testing, triage criteria, and medication management. This guideline provides a resource to the latest medical optimization guidance and alignment on the approach to preparing patients for surgery and procedures among the team.
41
Safety Quality Experience (continued)
Mount Sinai Health System Universal Protocol Universal protocol, including safety conversations, is one way we keep our patients safe. This year, we took further steps toward encouraging conversations from safety checklists, especially the debrief, as well as first steps toward moving universal protocol documentation off paper. The whole team participates to review key safety information during the debrief at the end of the case, and surgeons and nurses can now review the specimens together and sign off before they leave the room.
Debrief and Specimen Review 100% 90 80 70 60 50 40 30 20 10 0 August
September
October
November
2025 Surgeon
42
Staff
Surgeon and Staff
December
Safety Quality Experience | Documentation Compliance Targets (continued)
Upcoming 2026 Mount Sinai Health System Procedure for Scheduling Add-On/Emergency Cases to the Operating Room Providing access to the operating room for our patients and surgeons is paramount to perioperative services, yet challenges exist in a highly utilized and busy OR with limited resources. This policy establishes a structured approach to organize and prioritize patients with urgent or emergent surgical needs, ensuring that those with the most critical conditions receive timely and appropriate care. It supports optimization of resource allocation, particularly when operating rooms, personnel, and equipment are limited, and aims to minimize delays in lifesaving or limb-saving interventions. Additionally, the policy provides a systematic framework to classify patients and procedures based on severity so that the most critically ill receive the highest priority, reduce delays in time-sensitive interventions to prevent poor outcomes such as disability or death, and establish a standardized communication pathway with clearly defined categories to promote an efficient workflow while minimizing ambiguity and unnecessary debate.
Documentation Compliance Targets Documentation matters. It is how we communicate with our patients and colleagues, how we maintain compliance, and how we can help keep our patients safe. This year, our surgeons have done a great job working on timely and complete documentation, and we are excited to use tools and technologies to make their work even more efficient in the next year.
43
Documentation Compliance Targets (continued)
Pre-Procedural History and Physical (H&P) and Compliance
Co-sign available in Haiku
Specialty specific H&P templates launched
67%
MSH Hard Stop to Enter OR
2022-01
2023-01
2024-01
2025-12
Readiness Board reflects co-sign and interval
2025-01
Full Op Note Compliance
2024-12 67% 2022-12 60%
Standardized FON template launched
2022-01
2023-01
2024-01
2025-01
As of December 31, 2025, for the main operating rooms at Mount Sinai Brooklyn, The Mount Sinai Hospital, Mount Sinai Morningside, Mount Sinai Queens, and Mount Sinai West. 44
2025-12
71%
2023-12 62%
Sterile Processing Department
Sterile Processing Department Sterile Processing Department Leadership • William DeLuca, Senior Director of Sterile Processing, Mount Sinai Health System
Sterile Processing Department Mission To deliver excellence in surgical care through a unified, innovative, and datadriven Sterile Processing Department that ensures every instrument is safe and every tray is complete and ready when needed.
Initiative Summary We strive to set the standard for quality, efficiency, and reliability by leveraging advanced technology, proactive maintenance, and systemwide collaboration, supporting Mount Sinai’s mission to provide seamless, high-quality care for every patient, every time. The Mount Sinai Health System’s Sterile Processing Department has achieved major progress in efficiency, standardization, and patient safety. • A key milestone will be the conversion from CensiTrac to a newer, more efficient tracking system that improves visibility, reduces missing instruments, and streamlines workflows between the Sterile Processing Department and the OR. • The Preventive Maintenance Pilot at The Mount Sinai Hospital ensures trays are complete and instruments are functional before each case. Its success will lead to systemwide expansion, improving reliability, and reducing surgical delays. • Systemwide tray optimization is standardizing instrument sets, simplifying workflows, and cutting costs, while water quality testing aligns with new standards from the Association for the Advancement of Medical Instrumentation to enhance sterilization and instrument longevity. A decontamination area redesign with new washers further reduces turnaround times.
45
Sterile Processing Department | Patient Experience (continued)
• The System Sterile Process Committee is unifying these efforts through centralized leadership, best practices, and a digital tray request ticketing system to improve Sterile Processing Department-OR communication. • In 2025, more than 4,312 trays have been serviced, with projections surpassing 5,700 annually, ensuring instrument readiness, minimizing delays, and supporting Mount Sinai’s commitment to safe, efficient surgical care. • We are planning new system-standardized, AI-enhanced technology and needed physical renovations with upgrades in technology for 2026.
Patient Experience Surgical Patient Experience The goal of the Surgical Patient Experience (SPEX) initiative is to transform the ambulatory surgical experience across the Mount Sinai Health System, by bringing together interdisciplinary leaders to align insights from patient feedback, creating an environment of excellence through compassion, collaboration, and consistency for both patients and caregivers. Patient experience drives hospital ratings and rankings, and is linked with quality care, so this feedback is key to improving our ambulatory surgery experience. To initiate this project, Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) scores from sites were analyzed for key drivers (facility cleanliness, treated with courtesy and respect, comfort, and teamwork). The governance model across sites was also established, with teams at each site consisting of clinical, ancillary, and administrative representation, led by the site’s respective Patient Experience representatives. Each site team will analyze OAS CAHPS comments to uncover areas of opportunity, conduct root cause analyses, identify interventions, pilot them to gauge their success, and adapt workflows as appropriate while championing the changes. To date, the Mount Sinai Health System is improving at a greater rate than its ambulatory surgery peers, and most survey metrics have improved year over year relative to the set goals. We look forward to working with sites to learn about their successes and collaborate with them to achieve their goals.
46
National and Local Trends Ambulatory Surgery — Facility Rating 0–10 92%
Top Box Score
90
y = 0.128x + 86.814 y = 0.1237x + 85.326
88 86
Q1 2026 4.2% difference
84 Q1 2022 6% difference
82
y = 0.23x + 79.191
80 MSHS is improving at a greater rate than peers (2x faster), narrowing the gap over time. Goal is to sustain momentum while transitioning to top-tier performance!
78 76 Q1 2022
Q1 2023
Q1 2024
Q1 2025
Q1 2026
Quarter National
NYC
MSHS
Q1 2022
Q2 2022
Q3 2022
Q4 2022
Q1 2023
Q2 2023
Q3 2023
Q4 2023
Q1 2024
Q2 2024
Q3 2024
Q4 2024
Q1 2025
Q2 2025
Q3 2025
Q4 2025
Q1 2026
Diff.
-6.01
-5.72
-5.41
-7.70
-5.70
-4.72
-4.93
-6.16
-5.12
-3.76
-4.68
-4.65
-4.65
-3.78
-5.40
-5.48
-4.17
Base
85.64
85.03
85.07
86.76
85.77
85.96
86.64
86.44
86.54
86.65
86.63
86.40
86.91
86.85
87.61
87.52
87.05
Nat’l.
86.81
86.77
87.03
87.42
87.53
87.99
88.16
87.86
87.92
87.92
87.97
88.29
88.63
88.72
88.79
88.76
88.84
NYC
85.64
85.03
85.07
86.76
85.77
85.96
86.64
86.44
86.54
86.65
86.63
86.40
86.91
86.85
87.61
87.52
87.05
MSHS
79.63
79.31
79.66
79.06
80.07
81.24
81.71
80.28
81.42
82.89
81.95
81.75
82.26
83.07
82.21
82.04
82.88
47
Patient Experience (continued)
OAS CAHPS 2025 Performance MSHS Patient Experience Performance Compared to 2025 Goals
Mount Sinai Health System Ambulatory Surgery
2025 Goals Target Goal Based on top 50% of improvers
Stretch Goal Based on top 20% of improvers
2024 Performance
YTD 2025 Performance
Top Box
Percentile Rank
Top Box
Percentile Rank
Percentile Rank
Top Box
Percentile Rank
Top Box
Percentile Rank
Facility rating 0–10
82.01%
13
82.4%
12
83.59%
20
84.90%
27
Recommend the facility
81.07%
23
82.0%
26
81.90%
29
83.55%
36
Facility clean
94.67%
7
95.1%
7
95.58%
11
96.66%
20
Staff t eated with courtesy and respect
96.83%
17
96.8%
16
—
97.43%
28
97.83%
38
Staff ensu ed you were comfortable
94.45%
10
95.1%
15
95.27%
18
95.82%
25
Staff orked together to care for you
83.19%
7
84.7%
9
85.29%
13
87.09%
22
Metric
Global Metric
YOY
Improved YoY Meeting 2025 Site-Specific Target Goal
2024 date includes surveys returned from patients discharged from 1/1/2024–12/31/2024. Data retrieved 1/29/2025. 2025 data includes 1/1/2025–9/30/2025. Goal ranks are estimates based on the Jan 2025 Ranks Report (Oct 24–Dec 24). 48
Facility Rating Performance by Site CY 2024
Overall Facility Rating 0–10
Site-Specific Target Goal
Overall Facility Rating 0–10
Overall Facility Rating
Top Box
Percentile Rank
Top Box
Percentile Rank
YoY Change
Top Box
Percentile Rank
MS South Nassau ⭐
85.9%
29
87.1%
32
87.00%
39
Derfner ASC
88.6%
46
83.7%
25
89.06%
53
Mount Sinai Queens
86.3%
31
86.7%
27
87.01%
39
The Mount Sinai Hospital 🏆
81.7%
12
83.2%
15
83.27%
19
New York Eye and Ear Infirma y of Mount Sinai
81.6%
12
82.1%
12
83.11%
19
Mount Sinai Downtown Chelsea
88.4%
45
80.0%
10
88.90%
52
Mount Sinai West
80.6%
10
81.1%
9
82.08%
15
Mount Sinai Morningside
81.4%
12
80.0%
6
83.00%
18
Mount Sinai Downtown Union Square
81.3%
12
80.4%
8
82.85%
18
Mount Sinai Brooklyn
74.2%
2
73.8%
2
76.60%
4
Facility
Mount Sinai Health System Ambulatory Surgery
YTD 2025
Highest Performing Site Most Improved YoY Site Meeting 2025 Site-Specific Target Goal
49
Patient Experience | Perioperative Value Analysis (continued) Epic My Next Steps The Epic My Next Steps (MNS) Pre-Surgical Care Plan remains an Epic top five most engaged care plan for Mount Sinai, achieving a 50 percent engagement rate at the end of Q3 with continued quarterly growth. Since the pilot launch in September 2024 and systemwide rollout in November 2024, metrics have trended positively. Key improvements include higher on-time starts and fewer case cancellations, signaling stronger OR efficiency with close collaboration among perioperative teams and staff. Next steps include scaling to Endoscopy to broaden MNS’s procedural impact.
Perioperative Value Analysis The updated Perioperative Value Analysis structure strengthens collaboration between clinical leadership, supply chain, and finance to ensure evidence-based, cost-conscious decisionmaking in the OR. This enhanced model brings a clearer financial lens to product evaluations while amplifying clinician voice, ensuring that high-quality care and operational efficiency remain at the forefront. By aligning data-driven insights with real-world clinical experience, the new value analysis process supports smarter product adoption, better contract outcomes, and improved value across our perioperative services. In collaboration with Managed Care, Patient Financial Services, and the Central Billing Office, we have developed a streamlined process to analyze the margin for each product associated with specific procedure codes, enabling an accurate assessment of the perioperative impact to the organization—differentiated by Centers for Medicare and Medicaid Services and commercial payers.
50
Supply Management for Perioperative Services Leaders • Michael Arabia, MHA, Director of Logistics, Perioperative and Procedural Services, Mount Sinai Health System • Jeanne Chang, MS, RN, CNOR, Procedural Clinical Technology Director, Perioperative and Procedural Services, Mount Sinai Health System • Abbe Craven, MD, Director in Clinical Informatics, Digital Technology Partners and Perioperative and Procedural Services, Mount Sinai Health System • Suzie Meikuen Xie, MBA, PA-C, Senior Director of Clinical Operations, Perioperative and Procedural Services, Mount Sinai Health System Accurate Inventory Management is a collaborative initiative aligned with the systemwide launch of the Clarium Preference Card Optimizer and the restructuring of case booking from CPT codes to procedure-based nomenclature (as discussed in sections 4.2i and 4.2ii, “Leveraging Technology to Support Operating Room and Endoscopy Efficiency”). Our objective is to standardize and improve the accurate capture of supply utilization, enhance case preparedness, and establish a reliable feedback loop for preference card optimization and supply chain management. Through this initiative, we aim to create a dependable, efficient supply documentation process that ensures optimal resource availability, strengthens cost control, and supports clinical excellence. We will work closely with nursing teams and leverage enhanced vendor-supported tools to streamline workflows, improve charge capture accuracy, and optimize inventory management and overall perioperative cost performance.
Supply Management: Anesthesia Technology Operations: Conversions and Logistics Leaders • Michael Arabia, MHA, Director of Logistics, Perioperative and Procedural Services, Mount Sinai Health System • Joshua Villar, Senior Director, Anesthesiology Technology Operations, Perioperative and Procedural Services, Mount Sinai Health System Under the Supply Management: Anesthesia Technology Operations: Conversions and Logistics. 51
Perioperative Value Analysis (continued)
Key 2025 Anesthesiology Supply Initiatives • Cost Savings and Strategic Value: Partnering with the sourcing team, achieved $598,000 in direct cost savings through targeted supply conversions. • Operational Excellence, Innovation, and Logistics: Led multiple successful equipment trials and conversions, including sustainable and standardized solutions, such as reusable laryngoscope handles, CHG Tegaderm, and pediatric zinc tape. Integrated new technologies like General Electric anesthesia machines, Blink Technologies TwitchView, and Philips Transesophageal Echocardiography systems to enhance clinical capabilities. • Quality and Safety Enhancements: Collaborated with Pharmacy to implement Pyxis devices into the operating rooms, along with the Hyperkalemia Toolbox and KitCheck systems for medication safety.
System Health Care Asset and Redistribution Exchange (SHARE) Leaders • Michael Arabia, MHA, Director of Logistics, Perioperative and Procedural Services, Mount Sinai Health System • Suzie Mei Kuen Xie, PA-C, MBA, Senior Director of Clinical Operations, Perioperative and Procedural Services, Mount Sinai Health System, and Senior Program Director, Operating Room Operations, Departments of Neurosurgery and Otolaryngology, The Mount Sinai Hospital The SHARE initiative aims to optimize equipment utilization across procedural areas by maintaining accurate inventory levels in conjunction with redistributing available equipment to ensure strategic capital resource allocation to meet operational needs. Equipment is sourced from unused equipment within the Mount Sinai Health System and redistributed to Health System locations that need it. • $1.3 million cost avoidance in capital expenditure since its inception in September 2025 through December 2025 • 25 total assets distributed and growing
52
Endoscopy
Endoscopy Leaders • Maximilian Julian, MHSA, Director of Endoscopy Operations, Perioperative and Procedural Services, Mount Sinai Health System Overview Mount Sinai Health System Endoscopy Services encompass diagnostic-to-complex care in gastrointestinal procedural care. We deliver high-quality screening colonoscopies that strengthen our foundation in preventive care. At the same time, we continue to grow our capabilities in advanced therapeutic endoscopy, expanding both the complexity and sophistication of the procedures we provide. We expanded the delivery of advanced endoscopic procedures, including peroral endoscopic myotomy and endoscopic submucosal dissection, enhancing the scope and impact of minimally invasive therapies within the service. Our gastroenterology services have earned accolades that include: • No. 5 in Best Hospitals (Gastroenterology/GI Surgery) in U.S. News & World Report® rankings • No. 1 in NYC and No. 7 worldwide in Newsweek/Statista rankings Quality • Standardization of Pre-Procedural Protocols: Aligning bowel prep instructions, pre-procedure medication guidance, and patient teaching materials systemwide to ensure consistent communication and improved outcomes.
53
Endoscopy | Staff Experience (continued)
Patient Satisfaction • Epic My Next Steps Implementation (December 2025): Launching a new digital platform that sends pre-procedural instructions and educational materials to patients at scheduled intervals, improving preparedness, satisfaction, and procedural efficiency. Staff Engagement • We launched our first systemwide Endoscopy Safety Summit this year, creating a unified platform to review safety data, share best practices, and align standards across all sites. One hundred and twenty staff members participated, and we look forward to continuing this annual forum for years to come.
Staff Experience Your Voice Counts Survey
You Said It!
We Did It!
Your Voice Counts is Mount Sinai’s annual employee engagement survey. It provides staff with a confidential and easy way to share feedback on key workplace priorities such as safety, respect, and team culture. We thank everyone who completed this year’s survey and previous surveys. Your input helps leaders understand what matters most and drive meaningful improvements. Themes highlighted, including safety and respect, guided the work across the organization. Throughout the year, “You Said It, We Did It” icons reflected situations where staff ideas or requests led to real changes. Every voice mattered and feedback helped shape a stronger and more supportive workplace.
54
A Deeper Dive Into Safety: Main OR Teamwork and Resources See the Largest Improvement
Main OR 13% Resources & Teamwork
23%
13%
3.68
Respondent Distribution
+0.20
Score and Trend
Survey Items
My teamwork unit is adequately staffed.
29%
Communication between teams/work units is effective at Mount Sinai.
10%
25%
Different teams/work units work well together at Mount Sinai.
8%
24%
The amount of job stress I feel is reasonable.
23%
Communication between physicians, nurses, and other medical personnel is good at Mount Sinai.
9%
My team/work unit works well together.
6%
16%
There is effective teamwork between physicians/ 6% providers and nurses at this hospital/practice.
21%
22%
49%
3.25
+0.20
65%
3.72
+0.11
68%
3.78
+0.05
3.33
+0.12
3.74
+0.09
78%
4.07
+0.05
73%
3.91
+0.05
26%
25%
Unfavorable
51%
66%
Neutral
Statistically Significant
Favorable Not Statistically Significant
55
Staff Experience (continued)
Mount Sinai Safety Pulse
3.95 out of 5 - 0.05 vs. Overall Org. Avg. - vs. National Health Care (Employee) Avg. 2025 + 0.12 vs. 2024 results
Response Distribution
Items I feel free to raise workplace safety concerns.
6%
12%
82%
4%
13%
83%
6%
14%
80%
12%
11%
77%
9%
30%
61%
Mount Sinai provides high-quality care and service. Employees will freely speak up if they see something that may negatively affect patient care. Mount Sinai cares about the safety of its workforce. Mistakes have led to positive changes here.
Unfavorable
56
Neutral
Favorable
Mean Score
vs. National Health Care (Employee) Average 2025
vs. Historical (2024 Results)
4.11
-0.08
+0.22
4.06
-0.10
+0.15
4.03
-0.15
+0.07
3.84
-0.23
+0.18
3.66
-0.33
-0.08
Best and Most Improved Hospital in System Operating Room Efficiency The Mount Sinai Health System Operating Room Efficiency Awards recognize the power of coordinated teamwork, data-driven decision making, and a shared commitment to continuous progress. Presented quarterly, these awards highlight how improved operating room efficiency strengthens workflows, supports staff, and leads to better patient safety, satisfaction, and outcomes. They also remind us of the value of learning from one another, striving for consistency, and celebrating every achievement, large or small, that moves our teams and the Health System forward. These honors reflect the collective dedication of Perioperative and Procedural Services staff and inspire ongoing efforts to advance operational excellence across Mount Sinai.
Winners of the Q1 2025 Mount Sinai Health System Operating Room Efficiency Awards
Best Hospital in OR Efficiency for Q1 Mount Sinai Queens
Most Improved Hospital in OR Efficiency for Q1 The Mount Sinai Hospital
57
Staff Experience (continued)
Winners of the Q2 2025 Mount Sinai Health System Operating Room Efficiency Awards
Best Hospital in OR Efficiency for Q2 and Most Improved Hospital in OR Efficiency for Q2 (Tied) Mount Sinai Queens
Best Hospital in OR Efficiency for Q2 and Most Improved Hospital in OR Efficiency for Q2 (Tied) Mount Sinai West
58 Mount Sinai Annual Perioperative Report 2025
Key Initiatives
Winners of the Q3 2025 Mount Sinai Health System Operating Room Efficiency Awards
Best Hospital in OR Efficiency for Q3 Mount Sinai Queens
Most Improved Hospital in OR Efficiency for Q3 Mount Sinai Brooklyn
59
Winners of the Q4 2025 Mount Sinai Health System Operating Room Efficiency Awards
Best Hospital in OR Efficiency for Q4 Most Improved Hospital in OR Efficiency for Q4 (Three-Way Tie) Mount Sinai Queens
Most Improved Hospital in OR Efficiency for Q4 (Three-Way Tie) The Mount Sinai Hospital
Most Improved Hospital in OR Efficiency for Q4 (Three-Way Tie) Mount Sinai West
60
Looking Ahead 61
Strategic Goals and Objectives for Fiscal Year 2026
In addition to the initiatives for 2026 already mentioned, we will continue to lean into multidisciplinary partnerships to use data to understand where our opportunities are and whether our interventions are creating sustainable improvements in: • OR and endoscopic efficiency and utilization • Waste reduction and optimization of supply and capital equipment management • Optimization and alignment of best practices in OR management The progress we have made and the work we must continue will require collaboration and engagement from everyone who works in and supports the operating room and endoscopy suites.
62 Mount Sinai Annual Perioperative Report 2025
Looking Ahead
Appendix 63
Perioperative Services System Leadership Team*
Administrative Operations
Michael Arabia, MHA Director of Logistics, Perioperative and Procedural Services, Mount Sinai Health System
William DeLuca, CRCST Senior Director, Sterile Processing Department, Perioperative and Procedural Services, Mount Sinai Health System
Jonathan Scutchfield, MBA Director of Financial Planning and Analysis, Perioperative and Procedural Services, Mount Sinai Health System
Joshua Villar Senior Director, Anesthesiology Technology Operations, Perioperative and Procedural Services, Mount Sinai Health System
Maximilian Julian, MHSA Director of Endoscopy Operations, Perioperative and Procedural Services, Mount Sinai Health System
* Note: Each of our other team members is part of Perioperative and Procedural Services, Mount Sinai Health System. 64
Clinical Alignment
Neha Malhotra, MD, FACS, FAAP Medical Director, Procedural Quality, Perioperative and Procedural Services, Mount Sinai Health System
Jason Sangyoon Shin, DO Medical Director, Perioperative Medicine, Perioperative and Procedural Services, Mount Sinai Health System
Suzie Meikuen Xie, MBA, PA-C Senior Director of Clinical Operations, Perioperative and Procedural Services, Mount Sinai Health System
Associate Professor, Medicine (Hospital Medicine), Icahn School of Medicine at Mount Sinai
Senior Program Director, Operating Room Operations, Departments of Neurosurgery and Otolaryngology, The Mount Sinai Hospital
Clinical Operations
Maura Fran Carpo, RN, MSN, CNOR Tissue Compliance Officer, Perioperative and Procedural Services, Mount Sinai Health System
Ricardo A. Lazala, MD Vice Chair and Senior Director of Clinical Services, Cardiovascular Surgery, The Mount Sinai Hospital Director of Cardiovascular Surgery Clinical Services, Mount Sinai Health System
Assistant Professor, Cardiovascular Surgery, and Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai
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Perioperative Services System Leadership Team (continued)
Information Technology
Abbe Craven, MD Director in Clinical Informatics, Digital Technology Partners and Perioperative and Procedural Services, Mount Sinai Health System
Jeanne Chang, MS, RN, CNOR Procedural Clinical Technology Director, Perioperative and Procedural Services, Mount Sinai Health System
Andrey Sergeev Procedural Data and Dashboards Manager, Perioperative and Procedural Services, Mount Sinai Health System
Assistant Professor, Ophthalmology, Icahn School of Medicine
Nursing
Transformation and Process Improvement
Abigail Pfister Director, Strategic Initiatives and Operational Excellence, Perioperative and Procedural Services, Mount Sinai Health System
Nicole Ng, RN, MSN, CNOR Senior Director of Perioperative Nursing Practice, Perioperative and Procedural Services, Mount Sinai Health System, Senior Director of Perioperative Services, Mount Sinai South Nassau
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Appendix
Astrid Pineda, MPA Project Manager, Perioperative and Procedural Services, Mount Sinai Health System
Perioperative Services Hospital Leadership Team
Leadership
Jane Bautista, BSN, RN, CNOR Director, Perioperative Services, Mount Sinai-Union Square, The Blavatnik Family Chelsea Medical Center, Mount Sinai Health System
Leah Borenstein, MPA, RN, CNOR Vice President for Perioperative Services, Mount Sinai West and Mount Sinai Morningside
Yelena Bortnovskaya MSN, RN Senior Director, MSM
Michael Johnson, MHA, RN, CNOR Acting Vice President, Perioperative and Procedural Services, The Mount Sinai Hospital
Inga Meinikova DNP, FNP-C, RN
Nicole Ng, RN, MSN, CNOR Senior Director of Perioperative Nursing Practice, Perioperative and Procedural Services, Mount Sinai Health System, Senior Director of Perioperative Services, Mount Sinai South Nassau
Venetia Walker-Cowan, DNP, MBA, MSN, RN, NEA-BC, CPXP, CNOR, CSSM, CNAMB Director, Perioperative Services, Mount Sinai Brooklyn
Senior Director, MSW Perioperative Services
Perioperative Services
Maude Dodier, MSN, RN Director, Perioperative Services, Mount Sinai Queens
Minimol Shebeen, RN, MSN, CNOR Director, Perioperative Services, New York Eye and Ear Infirmary of Mount Sinai
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Acknowledgement of Partners
We would like to extend our sincere appreciation to Health System Operations, Data & Technology Partners (DTP), and the many other teams whose behind‑the‑scenes support was essential to advancing the complex and wideranging portfolio of Perioperative and Procedural Services initiatives in 2025. This work would not have been possible without their collaboration, expertise, and leadership. A very special thank you to some of our key partners:
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Betul Certel, Health System Operations
Juliet Montague, DTP
Ronen Dumov, Health System Operations
Daniel Mooney, DTP
Josephine Fang, DTP
Nicholas Morelli, Health System Operations
Michelle Fiks, Health System Operations
Andrew Nenos, Health System Operations
Michael Gonfiantini, Health System Operations
Terry Nucero, DTP
Gillian Hamilton, DTP
Shierlyn Ochotorena, DTP
Fiori Henry, DTP
Young-Shin Park, DTP
Brandon Hertel, DTP
Melanie Perl, Health System Operations
Faujia Islam, Health System Operations
Lauren Ritter, Health System Operations
Jeba Jebakumar, DTP
Mitali Thakore, Health System Operations
Angelea Johnston, DTP
Aditi Vakil, DTP
Gavin Lim, Health System Operations
Brandi Vaughan, Health System Operations
Casey Miller, Health System Operations
Saralynne Yorey, Health System Operations
Contact Info for Feedback or Engagement
For information, feedback, or engagement regarding the above matters, please contact: Astrid Pineda, MPA astrid.pineda@mountsinai.org Abigail Pfister abigail.pfister@mssm.edu Amanda Rhee, MD, MS amanda.rhee@mountsinai.org
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Proprietary and Confidential