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2025 Annual Quality and Patient Safety Report

Department of Medicine Icahn School of Medicine at Mount Sinai Mount Sinai Health System

Table of Contents Mount Sinai Health System ..........................................................................................................2 Department of Medicine Quality Leadership .............................................................................. 2 Mount Sinai Downtown Division Quality Champions .............................................................. 3 The Mount Sinai Hospital Division Quality Champions .......................................................... 3 Mount Sinai Morningside and Mount Sinai West Division Quality Champions ...................... 3 Community-Based Hospitals Quality Champions ................................................................... 3 Hospital at Home Quality Champion ....................................................................................... 3 Central Hospitalist Quality Champion: .................................................................................... 3 Introduction .................................................................................................................................. 4 Quality at a Glance.........................................................................................................................6 2025 Department of Medicine Patient Experience Awardees .................................................... 7 Clinical Allergy and Immunology .................................................................................................8 Endocrinology ............................................................................................................................. 10 Gastroenterology ........................................................................................................................ 15 General Medicine ........................................................................................................................ 21 Hospital Medicine ....................................................................................................................... 39 Central Hospitalist ...................................................................................................................... 63 Hospital at Home......................................................................................................................... 66 Quality Improvement Peer Reviews (QIPR) ............................................................................. 73 Infectious Diseases .................................................................................................................... 93 Liver Medicine ............................................................................................................................. 99 Nephrology ................................................................................................................................ 104 Pulmonary, Critical Care and Sleep Medicine ....................................................................... 111 Rheumatology ........................................................................................................................... 119 Publications, Presentations, and Grants ............................................................................... 123 The Mount Sinai Downtown Publications ............................................................................... 123 The Mount Sinai Hospital Publications ................................................................................... 123 The Mount Sinai Hospital Presentations (Abstracts and Workshops) ................................... 123 The Mount Sinai Hospital Grants/Awards ............................................................................... 125 Mount Sinai Morningside and Mount Sinai West Publications ............................................... 125 Mount Sinai Morningside and Mount Sinai West Invited Presentations ................................ 126 Mount Sinai Morningside and Mount Sinai West Presentations (Abstracts and Workshops) ............................................................................................................................. 126 Mount Sinai Morningside and Mount Sinai West Grants/Awards .......................................... 127 Mount Sinai Hospital at Home Publications ............................................................................ 127 Mount Sinai Hospital at Home Presentations (Abstracts and Workshops) ............................ 127 Mount Sinai Hospital at Home Invited Presentations ............................................................. 128 Mount Sinai Queens Presentations (Abstracts and Workshops) ........................................... 128 Mount Sinai South Nassau Publications ................................................................................. 129 Mount Sinai South Nassau Presentations (Abstracts and Workshops) ................................. 129

Annual Quality and Patient Safety Report

Mount Sinai Health System Department of Medicine Quality Leadership Beth Raucher, MD, SM System Vice Chair, Quality & Clinical Affairs Department of Medicine, Mount Sinai Health System Vinh-Tung Nguyen, MD Chair, Quality Improvement Committee Department of Medicine, The Mount Sinai Hospital Jing Wang, MD Chair, Quality Improvement Committee Department of Medicine, The Mount Sinai Hospital Patricia Dharapak, MD Chair, Quality Improvement Committee Department of Medicine, Mount Sinai-Union Square Amy Rosenberg, MD Associate Chair, Administrative Affairs Department of Medicine, Mount Sinai Morningside and Mount Sinai West Julie Pearson, MPH, RN Director, Performance Improvement & Analytics Department of Medicine, Mount Sinai Health System Umar Jalloh, MPA, CPHQ, CPPS Manager, Performance Improvement & Research Department of Medicine, Mount Sinai Health System Benjamin Dempsey, MHA Quality Analyst Department of Medicine, Mount Sinai Health System Orie Wittek, MD Quality and Regulatory Affairs Specialist, Department of Medicine Liaison The Mount Sinai Hospital

Annual Quality and Patient Safety Report

Mount Sinai Downtown Division Quality Champions Clinical Immunology: Songhui Ma, MD Endocrinology: Daniel Donovan, MD; Olga Kozachenko, NP-C Gastroenterology: Custon Tafadzwa Nyabanga, MD; Joseph Mizrahi, MD* General Internal Medicine: Desiree Chow, MD Infectious Diseases: Tessa Gomez, MD; Sarah Humphreys, MD Nephrology: Elliot Charen, MD Pulmonary, Critical Care and Sleep Medicine: David Steiger, MD; Boram Kim, DO*; Boris Gilyadov, MD*

The Mount Sinai Hospital Division Quality Champions Clinical Immunology: Eugene Choo, MD Endocrinology: David Lam, MD; Nirali Shah, MD Gastroenterology: Christopher Cao, MD; David Greenwald, MD General Internal Medicine: Kelsey Bryant, MD; Doug Halket, MD*; Alison Koransky, MD* Hospital Medicine: Anne Linker, MD Quality Improvement Peer Review Committee: Aveena Kochar, MD Infectious Diseases: Rachel Chasan, MD Liver Diseases: Douglas Dieterich, MD; Frances Lee, MD; Anna Mageras, MPH Nephrology: Joji Tokita, MD; Niraj Kothari, MD Pulmonary, Critical Care and Sleep Medicine: Jing Wang, MD; Timothy Harkin, MD Rheumatology: Wendy Weiwei Chi, MD

Mount Sinai Morningside and Mount Sinai West Division Quality Champions Endocrinology: Ilana Ramer Bass, MD Gastroenterology: Tina Park, MD General Internal Medicine: Heather Viola, DO; Christopher Gold, DO Hospital Medicine (MSM): Brian Markoff, MD; Faye Reiff-Pasarew, MD Quality Improvement Peer Review Committee: Lindsey Fox, MD Hospital Medicine (MSW): Shantheri Shenoy, MD Quality Improvement Peer Review Committee: Irina Zaretsky, MD Infectious Diseases: Rahul Gaikwad, MD Nephrology: Claire Schretlen, MD Pulmonary, Critical Care and Sleep Medicine (MSW): David Steiger, MD Pulmonary and Critical Care (MSM): Avinash Singh, MD Rheumatology: Kristaq Koci, MD; Saloni Mitchell, MD*

Community-Based Hospitals Quality Champions Mount Sinai Brooklyn: Radfan Gazali, MD Mount Sinai Queens: Kathy Navid, MD; Allegra Lee, MD Mount Sinai South Nassau: Aaron Glatt, MD; Dmitry Konsky, DO

Hospital at Home Quality Champion: Tuyet-Trinh Truong, MD Central Hospitalist Quality Champion: Samuel Hundert, MD * New Department of Medicine Quality Champion beginning in 2025.

Annual Quality and Patient Safety Report

Introduction Dear Colleagues, I am pleased to share the Department of Medicine’s 2025 Annual Quality and Patient Safety Report. This year’s report highlights continued progress in delivering high-quality, safe, and patient-centered care across the Mount Sinai Health System, reflecting the collective efforts of our faculty, trainees, quality champions, and partners. This year, we are especially pleased to highlight the growing quality and patient safety work taking place at our community-based hospitals—Mount Sinai South Nassau (MSSN), Mount Sinai Brooklyn (MSB), and Mount Sinai Queens (MSQ)—in keeping with the Health System’s priority of One Mount Sinai. Interdisciplinary groups at these sites are leading impactful initiatives tailored to their patient populations while aligning with systemwide goals, and their contributions are reflected throughout this report. Guided by our Division Quality Champions and supported by my amazing team, 2025 was marked by sustained project momentum and meaningful impact. As illustrated in Quality at a Glance, our faculty, residents, and students continued to implement a broad portfolio of quality improvement initiatives spanning inpatient, ambulatory, and transitional care settings. These projects addressed priority domains such as safe transitions, medication safety, inpatient mobility, infection prevention, chronic disease management, length of stay, and patient education—building on the strong foundation established in prior years. A continued emphasis on patient safety culture remains central to our work. Real-time review of SafetyNet reports, mortality reviews, and peer review allows us to rapidly identify opportunities for improvement, implement corrective actions, and share best practices across sites. The engagement of faculty from the Division of Hospital Medicine and our interdisciplinary committee members strengthens this learning system and supports timely action to reduce risk and improve outcomes. Data and analytics once again played a critical role in driving improvement. Our quality analysts supported champions with timely, meaningful data extracted from Epic, Vizient, and Tableau, enabling teams to track focused progress. In 2025, we also began adopting AI-supported tools in several areas of our work. These technologies help us identify patterns more efficiently, prioritize cases for deeper review, and enhance our ability to learn from events while maintaining the rigor and clinical judgment essential to these processes. We also continued to benefit from strong leadership development and collaboration across the Department and Health System. Faculty trained through the GNYHA/UHF Clinical Quality Fellowship and other programs and partnerships with hospital quality leadership, CMOs, and the MSHS Office of Risk Management and Quality and Regulatory Affairs continue to support the spread and sustainability of effective practices. I am deeply grateful to our site-based quality leads, Division Quality Champions, and the outstanding quality and data team who support this work every day. I also thank our faculty and trainees, whose creativity and commitment are increasingly being recognized by national societies through invited presentations and by impactful journals through peer-reviewed publications—extending the reach of this work well beyond our institution. Annual Quality and Patient Safety Report

I invite you to explore the pages that follow and take pride in what we have accomplished together. I look forward to building on this progress in the year ahead as we continue our shared mission of delivering the safest, highest-quality care possible. Respectfully,

Beth Raucher, MD, SM System Vice Chair, Quality & Clinical Affairs Professor Department of Medicine Mount Sinai Health System

Annual Quality and Patient Safety Report

Quality at a Glance

Annual Quality and Patient Safety Report

2025 Department of Medicine Patient Experience Awardees The Department of Medicine congratulates the outstanding faculty, advanced practice providers, and residents across Mount Sinai Brooklyn, Mount Sinai Downtown, The Mount Sinai Hospital, Mount Sinai Morningside and Mount Sinai West, Mount Sinai Queens, and Mount Sinai South Nassau whose work was recognized by peers in 2025.

Cullman Family Awardees for Excellence in Physician Communication

STAR Award Recognition Recipients

Annual Quality and Patient Safety Report

Clinical Allergy and Immunology

Penicillin and Beta-Lactam Allergy Projects The Division of Allergy and Immunology continued to advance systemwide quality initiatives with a particular focus on improving the evaluation and management of penicillin and beta‑lactam allergies. At Mount Sinai-Union Square, the initiative began with creating a dedicated procedure room and training nurses to complete penicillin skin testing and challenges, including the management of anaphylaxis. Appointment availability increased 50 percent after hiring an NP in 2024. To further improve penicillin de-labeling in 2025, the division at Mount Sinai Downtown partnered with GMA to identify and refer patients through targeted bulk MyChart messages to patients. From 2023 to 2024, there was an increase in the number of patients for whom the allergy was addressed (from 76 to 82), tested (37 to 43), and de-labeled (37 to 42). From September 2024 to March 2025, direct challenge was completed on 59 of the 60 patients for whom it was recommended. This work ended in mid-2025 following Dr. Ma’s departure from the Health System. However, de-labeling work continues in GMA and at MSH with the hope of dissemination throughout the system. A validated PEN‑FAST–based Epic dot phrase was developed at MSH in 2025 to support consistent risk stratification and guide clinicians toward the most appropriate management pathways for patients with a listed penicillin allergy, including continued avoidance, skin testing with graded oral challenge, or graded oral challenge alone. This tool was shared within the Allergy/Immunology division and the multidisciplinary penicillin allergy workgroup, which includes Infectious Diseases and Internal Medicine. Information Technology is now working to convert the dot phrase into a dropdown Epic menu to enhance accessibility and usability across all specialties throughout the Health System.

Annual Quality and Patient Safety Report

Regular meetings of the penicillin allergy workgroup occur every two to three months to review future directions related to antibiotic recommendations and potential de-labeling strategies. Educational outreach has remained a priority, with lectures on updated beta‑lactam recommendations delivered to a wide range of services across the Mount Sinai Health System, including Infectious Diseases, Anesthesia, Internal Medicine, OB/GYN, and Pediatrics. As part of this initiative, fellow Dr. Catherine Ye is assessing the impact of these sessions through pre‑ and post‑lecture evaluations, with support from Internal Medicine resident Dr. Emily Wang. Dr. Ye presented early findings from this work at the American College of Allergy, Asthma and Immunology meeting in November 2025. In collaboration with Infectious Diseases, the division also developed an updated beta‑lactam decision pathway that will replace prior guidance across the Mount Sinai Health System. This revised pathway offers clearer, more contemporary recommendations regarding which beta‑lactams should be tested or avoided in patients with penicillin or cephalosporin allergy, with specific consideration for cephalosporins that do not share identical side chains with implicated penicillins. MSHS Multidisciplinary Contrast Committee Additionally, Allergy and Immunology faculty member Dr. Maria Shtessel continues to serve on the systemwide contrast committee, which brings together Allergy, Radiology, Cardiology, and Anesthesia. The committee is focused on creating a standardized policy for managing iodinated contrast reactions, ensuring alignment with current evidence and community standards, and developing coordinated Epic workflows to support consistent practice across the system. This work will continue in 2026.

Annual Quality and Patient Safety Report

Endocrinology

In 2025, the Division of Endocrinology at Mount Sinai Morningside/West (MSMW), The Mount Sinai Hospital (MSH), and Mount Sinai Downtown led multiple quality improvement initiatives addressing diabetes, obesity, liver disease, and chronic kidney disease. Al though completed at individual sites, these projects reflect a shared systemwide strategy: improving outcomes through proactive, guideline-driven care, technology-enabled workflows, and patient engagement. Across sites, initiatives focused on two core priorities: •

Closing gaps in evidence-based quality recommendations, including metabolic dysfunction-associated steatotic liver disease (MASLD) screening, preoperative diabetes optimization, kidney-protective therapies, use of medications to manage hyperlipidemia and hypertension, and safety planning for insulin pump users.

•

Improving patient engagement and self-management, through weight management resource connections and structured diabetes education.

Annual Quality and Patient Safety Report

Mount Sinai Morningside/West 2025 Quality Improvement Highlights During 2025, the MSMW Division focused its quality improvement work on closing gaps in guideline-directed care, improving screening for high-risk conditions, and strengthening patient engagement in chronic disease management. One major initiative addressed preoperative diabetes optimization. The project targeted patients with type 2 diabetes undergoing elective surgery and sought to improve glycemic control prior to the procedure. Using a structured framework that incorporated nurse practitioner/ diabetes educator visits, continuous glucose monitor (CGM) use, and treatment intensification, the team aimed to achieve an appropriate preoperative fructosamine level (equivalent to an HgA1c below 8 percent) in a timely fashion. This work established a standardized pathway for identifying and optimizing high-risk surgical patients and reinforced collaboration between endocrinology and primary care. Another project focused on connecting patients with weight management resources. Recognizing that many patients were not utilizing available lifestyle and behavioral support, the team integrated counseling aids and EMR SmartPhrases into clinic workflows and provided patient-facing materials with QR codes linking to resources. Over the project period, 50 patients received materials, with follow-up data available for 26. Of those, five patients (19 percent) were documented to have engaged in lifestyle changes, such as starting nutrition counseling, exercise programs, or support groups. Engagement with QR code resources was higher among patients who made lifestyle changes (80 percent) compared with those who did not (14 percent), although overall engagement remained below the target. The project provided important insights into patient engagement strategies and is being expanded to additional clinics and patient populations. The Division also implemented a MASLD screening initiative for patients with obesity and type 2 diabetes. Prior to the intervention, only 1 percent of eligible patients were screened using the FIB-4 score. The project combined fellow education with an EMR SmartPhrase to streamline screening during routine visits. Within five months, screening rates increased substantially, reaching between 11 percent and 28 percent across monthly measurement periods. Provider surveys showed increased awareness and stronger agreement that MASLD screening is a core responsibility of endocrinologists. This project demonstrated that targeted education paired with simple EMR tools can rapidly improve adherence to evolving clinical guidelines. The Mount Sinai Hospital 2025 Quality Improvement Highlights In 2025, the MSH Division focused its quality improvement efforts on patient safety, increased adoption of diabetes technology, and optimization of evidence-based therapies for diabetic complications. These projects emphasized EMR-enabled workflows and standardized processes to improve consistency of care. A key safety initiative addressed the need for back-up basal insulin prescriptions for patients using insulin pumps. Continuous insulin delivery is essential for patients with type 1 Annual Quality and Patient Safety Report

diabetes, and the absence of back-up insulin during pump malfunction can increase the risk of diabetic ketoacidosis and lead to urgent provider contacts. The Division conducted three PDSA cycles to improve identification of pump users and ensure appropriate prescriptions. The final intervention used ICD-10 coding to identify pump users in the EMR and automatically send MyChart reminders prior to appointments, prompting patients to confirm that they had back-up insulin and discuss this with their provider if needed. This resulted in a standardized, systembased safety process. The Division also launched a major initiative to increase adoption of diabetes technology, including CGMs and insulin pumps with automated insulin delivery algorithms. Despite strong guideline recommendations, technology use varied significantly across insurance types and practice settings, with the largest disparities observed among Medicaid populations. Through this project, barriers were identified at the provider, patient, and system levels, including clinician unfamiliarity with ordering processes, insufficient patient training, insurance restrictions, and lack of standardized workflows. The most successful strategies were EMR-integrated tools, including SmartPhrases that guided clinicians through the ordering process and educator referral pathways to support patient decision-making. Educational sessions for fellows were retained, while less effective strategies—such as pre-visit messaging and manual identification of eligible patients—were discontinued. This work highlighted the importance of embedding decision support directly into clinical workflows.

A new project, FINER Care, was launched to improve treatment of diabetic nephropathy. Despite strong evidence supporting the use of finerenone (Kerendia) and SGLT2 inhibitors to reduce adverse kidney and cardiovascular outcomes, adoption of finerenone has been limited due to uncertainty about eligibility, workflow complexity, and monitoring concerns. To address these barriers, the division is developing an EMR Office Practice Advisory (OPA) to identify eligible patients and prompt appropriate prescribing. The project’s aim is to increase finerenone prescribing by 25 percent within six months. This work will continue in 2026.

Annual Quality and Patient Safety Report

Overall, the MSH initiatives focused on improving safety, expanding access to advanced diabetes technologies, and promoting adoption of evidence-based therapies for diabetes-related chronic kidney disease. Across projects, EMR-integrated tools and standardized workflows emerged as the most effective drivers of practice change. Mount Sinai Downtown The Division at Mount Sinai Downtown focused on three quality metrics to close the gap in evidence-based quality recommendations. The first goal of improving statin therapy usage remained stable at approximately 87 percent at the end of 2025, with ongoing education and multipronged approaches contributing to progress. To further improve this metric, the Division planned to expand provider education and conduct periodic performance feedback reviews to reinforce guideline-concordant therapy and address remaining gaps in care. The second goal regarding ACE inhibitors and angiotensin receptor blockers achieved ~65 percent implementation, falling short of the 83 percent target but remaining relatively stable across different ethnic groups. (See graphs below.) To address the gap toward the target, planned

Annual Quality and Patient Safety Report

interventions included reinforcing provider education on guideline‑directed use of ACE inhibitors and ARBs and reviewing cases of nonuse to address clinical contraindications or prescribing barriers. The third goal of urine microalbumin creatinine examinations reached 91-95.8 percent implementation rates in the first three months of the year, exceeding the target requirement. To sustain and further strengthen performance despite exceeding the goal, planned efforts focus on maintaining standardized ordering through Epic and periodic auditing to reduce variability in practice.

Diabetic Patients on Statin Therapy 90.5%

92.00% 90.00% 88.00%

85.6% 86.00% 83.70% 84.00%

86.6% 87.2%

87.1% 84.1%

85.1% 85.0%

84.8%

86.1%

86.9% 87.5%

87.3% 87.0%

82.00% 80.00% 80.00% 78.00%

76.00% 74.00%

% on Statin

Goal

Diabetic Patients % on ACEI + ARB 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%

68.40%

61.70%

66.90% 66.00% 64.40%

63.20% 64.20% 65.40% 64.70% 64.20% 66.15% 65.93% 62.20% 65.99% 65.73%

ACEI + ARB Percent

Annual Quality and Patient Safety Report

Goal

Gastroenterology

In 2025, the Division of Gastroenterology at MSH, MS Downtown, and MSMW engaged in several new quality initiatives. Colonoscopy Optimization and Quality Metrics The first of these involved compiling updated data to measure quality metrics of endoscopy within the division at MSH. Indicators of a thorough examination during a colonoscopy include cecal intubation rate (CIR), adenoma detection rate (ADR), sessile serrated lesion detection rate (SSLDR), scope withdrawal time (SWT), and percentage of colonoscopies with adequate bowel preparation as measured by the Boston Bowel Prep Score (BBPS). Colonoscopy bowel preparation adequacy is defined as the percentage of patients undergoing colonoscopy with adequate bowel preparation. The national performance threshold

Annual Quality and Patient Safety Report

is recommended to be > 90 percent. The Division exceeds this threshold with a bowel preparation adequacy rate of 91 percent. Cecal intubation rate is defined as the percentage of colonoscopies in which the cecum was successfully intubated. The national benchmark has a goal rate of 95 percent of all colonoscopies. In the most recent quarter, the Division’s mean CIR was 96 percent, exceeding the recommended national benchmark. An additional indicator of thorough examination is adenoma detection rate. The goal is detection of adenoma in 35 percent of patients—40 percent in males and 30 percent in females—undergoing average risk colon cancer screening. The current ADR of the Division is 45 percent, which exceeds this goal. A comparative indicator of a careful colonoscopy is sessile serrated lesion detection rate with a performance threshold set at > 6 percent. The current SSLDR of the Division is 7.9 percent. Utilizing scope withdrawal time as an endoscopy quality metric ensures that adequate time is spent visualizing the colon and is defined by the time of colonoscope retraction after the cecum has been reached. National guidelines recommend a SWT of > 8 minutes. At MSH, the Division has also exceeded this benchmark, with the most recent SWT among the Division averaging 9.8 minutes. 2025 MSH Endoscopy Quality Metrics

At MSH, the Division continues to track and report the percentage of colonoscopies with adequate bowel prep by utilizing the Boston Bowel Preparation Scale. BBPS is a standardized, validated scoring system used to determine the quality of bowel preparation. Providers document the cleanliness of three sections of the colon using an objective, zero to three scoring system. An adequate bowel prep is critical in allowing for optimal conditions to identify bowel pathology but has been an ongoing challenge. This year, the Division has been working to improve bowel prep in patients admitted to the hospital with three main goals: decrease patient delays for inpatient colonoscopy, streamline communication regarding bowel prep quality, and perform health equity analysis by age and preferred language. Preliminary data shows that 47 percent of colonoscopies in the inpatient setting at MSH were delayed due to inadequate bowel prep. To improve colonoscopy bowel preparation adequacy rates and timeliness to procedure, the Division implemented an inpatient checklist and developed an Epic order set to improve workflow. The checklist and order set involved standardizing

Annual Quality and Patient Safety Report

preoperative laboratory testing, advancing timing of bowel preparation medication to an earlier period, and incorporating nursing into this workflow by asking for photos of bowel movements to be uploaded into Epic after intake of bowel preparation so that teams could assess adequacy of bowel preparation and if additional bowel preparation was needed. As a result of this initiative, morning readiness of colonoscopy increased by 62.7 percent while procedure cancellations decreased by 40.5 percent. Nursing photo documentation increased from 47.5 percent to 78.1 percent. In the post-intervention cohort, earlier prep order time was independently associated with morning readiness. The odds of readiness were reduced by 61 percent with each hour delay in prep ordering. Average Boston Bowel Preparation Scale scores remained adequate pre- and post-intervention. Patient Safety and Procedure Readiness At MSH, the Division has worked on improving rates of cancelled endoscopic procedures due to glucagon-like peptide-1 receptor agonists (GLP-1 RA). GLP-1 RAs have risen in popularity given their weight loss properties through delaying gastric emptying and increasing satiety. The theoretical risk of GLP-1 RA includes gastric retention and aspiration during endoscopies. Anesthesia guidelines had recommended holding GLP-1 RA prior to endoscopic procedures and procedures were cancelled if this medication had not been sufficiently held prior to the procedure. This guideline change resulted in an increased risk of endoscopy cancellations: in the second half of 2023, 24 percent of patients taking a GLP-1 RA experienced a procedural cancellation. To address this high rate, the GI team at MSH first performed a retrospective chart review, evaluating the percentage of aborted procedures due to food retention in patients on a GLP-1 RA. Data revealed a slight increase in aborted procedures in patients on a GLP-1 RA but the absolute number of aborted procedures remained low.

Annual Quality and Patient Safety Report

Additionally, the Division created pre-procedural instructions for patients on a GLP-1 RA, giving detailed instructions about when their medication should be held and what their diet should consist of prior to procedure (intervention 1). Later, a Mount Sinai systemwide change in policy advised that patients only need their GLP-1 RA to be held for one dose prior to endoscopy rather than the previously recommended two doses (intervention 2). Through these interventions, the Division noted a drastic decline in the rates of procedural cancellations in patients on a GLP-1 RA.

The results of this project were published in the Digestive Diseases and Sciences journal. Based on prior work at MSMW to improve percutaneous endoscopic gastrostomy (PEG) tube placement workflow and outcomes, the Division worked to create a PEG checklist and order set at MSH. Prior to this initiative, the mean time of PEG consult request to placement of PEG at MSH was 3.65 business days (i.e., Monday thru Friday, excluding holidays). Reasons for delay that were identified on a pre-intervention survey included gap in knowledge regarding indications for PEG placement and inadequate optimization of patient conditions prior to PEG consult (i.e., actively infected, receiving blood thinners, etc.). The aims of this checklist were to streamline the referral processes, decrease time from consult to PEG placement, and allow for appropriate identification of patients eligible for PEG placement. Use of the order set was well received by primary teams.

Annual Quality and Patient Safety Report

From this initiative, the primary outcome measure of time from PEG consult to PEG placement also decreased from a mean of 3.65 business days to 1.95 business days. This data has been presented at the most recent American College of Gastroenterology Meeting.

At MSMW, there is also a project led by Dr. Joseph Abraham and Dr. Frank Nelson that sought to improve timely paracentesis. Guidelines recommend paracentesis within 12-24 hours of admission to reduce mortality, length of stay, and ICU days. The initiative used a secure chat to connect paracentesis-certified faculty and residents with the learner, with the goals of decreasing the time to paracentesis, as well as improving procedural safety, streamlining the workflow, and building competency. After implementation of the secure chat, the proportion of paracentesis notes filed within 48 hours increased from 35 percent to 51 percent postintervention—a relative improvement of 46 percent.

Annual Quality and Patient Safety Report

sTEEring Clear: Avoiding Unnecessary GI Consults Prior to TEE Dr. Joseph Mizrahi and Dr. Adam Tillowitz at MS Downtown and MSMW started a project examining the overuse of GI consults prior to transesophageal echocardiogram (TEE). Cardiologists often consult GI for clearance when a patient needs a TEE and has a contraindication such as esophageal strictures, history of or active upper GI bleed, history of dysphagia, or peptic ulcer disease. However, there is little evidence that these consults improve patient outcomes or prevent procedural complications, and they often cause delays for the TEE and increase length of stay. This project aims to decrease unnecessary consults through coordination with and education of both the Cardiology and Gastroenterology departments. Baseline data collection started in 2025 and the project will continue into 2026. Patient-Centered Care and Experience Led by Dr. Sonia Mehra and Dr. Yuying Luo, patients at MSMW who were referred to direct access colonoscopy were asked about their gender preference for their endoscopist by including the question into the routine screening questions. Of the 49 patients who were asked about their gender preference (25 female, mean age 55.8 ± 11.1 years), nine patients (18.4 percent) expressed a preference. Among those who had undergone a prior colonoscopy, including both patients with (n=2) and without a gender preference (n=8), 66.7 percent reported their current procedure to be more satisfying compared to their previous procedure. Inquiring about gender preference may improve overall satisfaction even if patients do not have a gender preference. Clinical Effectiveness and Care Management Triple therapy for Helicobacter pylori (H. pylori) infection is often considered first-line treatment and includes proton pump inhibitors (PPIs), clarithromycin, and amoxicillin (or metronidazole if patient is penicillin allergic). More recent guidelines state that triple therapy for H. pylori infection should not be used unless antibiotic sensitivity testing has been performed and clarithromycin sensitivity is demonstrated. Instead, quadruple therapy including PPIs, bismuth salt, tetracycline, and metronidazole is recommended. At MSMW, an educational initiative was developed by Dr. Rama Hussein and Dr. Zoe Lawrence, who created a visual aid to increase ease of medication adherence. The project is ongoing, however, since implementation, compliance with quadruple therapy has increased to 100 percent from 50 percent. All of these patients were recommended to have follow-up, of which 69 percent were scheduled, and 50 percent completed the appointment. An educational session for residents is scheduled for early 2026.

Annual Quality and Patient Safety Report

General Medicine

Division of Internal Medicine Quality Champions: Kelsy Bryant, MD, Alison Koransky, MD, and Doug Halket, MD (MSH); Heather Viola, DO, Christopher Gold, DO, and Desiree Chow, MD (MSMW), with portraits. In 2025, the Division of General Medicine across Mount Sinai, including Internal Medicine Associates (IMA), General Medical Associates (GMA), and Mount Sinai Morningside and West practices, continued quality improvement efforts focused on chronic disease management, preventive care, and care delivery optimization. Division-wide priorities included improving hypertension and diabetes control, increasing screening for diabetic complications, and strengthening evidence-based preventive services, with site-specific emphasis on MSHPaligned quality measures, vaccination rates, and appropriate medication use. Additional focus areas included team-based care, cancer screening adherence, naloxone prescribing for highrisk patients, improved transitions of care, and enhanced clinical documentation in Epic.

Annual Quality and Patient Safety Report

Ambulatory Care Quality Dashboard Across the system, the Division leveraged data from the Ambulatory Care Quality Dashboard to drive improvements in all quality measures, supporting commitment to excellence in patient care. Residents are now also trained to use the dashboard during their scheduled education sessions, ensuring they are equipped to incorporate data-driven approaches into their practice. The dashboard, originally piloted by early adopters in 2023, was fully integrated into quality improvement workflows across the system in 2025. This comprehensive tool provides real-time data at the system, department, clinic, and provider levels, and includes population outreach features, such as batch messaging for patients with open care gaps and batch ordering for cancer screenings. These innovations continue to enhance efficiency and effectiveness in addressing care gaps across the population. Chronic Disease Management Hypertension The Division remained steadfast in its commitment to achieving optimal blood pressure (BP) control. In 2025, IMA partnered with the American Medical Association to adopt their MAP BP framework. This consisted of support to Measure Accurately, Act Rapidly, and Partner with Patients. Other key initiatives included standardizing workflows for both in-office and at-home BP monitoring, complemented by an innovative remote patient monitoring program. Through the partnership, the Division started using office blood pressure, an average of three readings, which is thought to be more accurate. The interdisciplinary, team-based approach driving these efforts is illustrated in the workflow diagram below.

Annual Quality and Patient Safety Report

Internal Medicine Associates Hypertension Pathway

Hypertension Control In 2025, efforts to improve hypertension (HTN) control at the system level expanded under the leadership of Dr. Bryant, who conducted a comprehensive analysis of systemwide data. This work focused on understanding the use of the last recorded blood pressure as a proxy for control, given the dynamic nature of BP measurements. Unlike static quality metrics such as diabetic nephropathy or retinopathy screening, hypertension control fluctuates as it is calculated based on the most recent ambulatory BP recorded in the system. Real-time insights into patients’ changing control status remained critical for effective population-level management. A research manuscript is currently under review at a major journal. In 2025, two abstracts related to hypertension control were presented at the American College of Cardiology National Meeting in March 2025 and the Society of General Internal Medicine in May 2025. Additional academic activity related to hypertension included a clinical update and workshop presented by Dr. Bryant at the Society of General Internal Medicine in May 2025. She was also invited to speak on AI in Hypertension at American Heart Association hypertension sessions in September 2025 and present a clinical case at American Heart Association scientific sessions in November 2025. Home Blood Pressure Monitor Campaign Home BP monitor access continued through a partnership with Integra (a benefits manager) by creating a closed-loop feedback process to track orders. In 2025, IMA ensured devices

Annual Quality and Patient Safety Report

dispensed had passed a validation process for accuracy and were nationally recognized on validatebp.org.

Control Rates Through targeted outreach using the hypertension control dashboard and ongoing education on best practices, including the prescribing and use of single-pill combinations, the hypertension control rate remained consistently above 70 percent since May 2024 and surpassed 73 percent as of July 2024. Control rates continue to steadily improve and will be tracked through 2026.At GMA, hypertension control was maintained by continuing a multipronged approach of repeating elevated readings and documenting home recordings, referring appropriate patients to the remote patient monitoring program, and conducting monthly nursing outreach to patients with uncontrolled blood pressure to review medications and home blood pressure readings in between visits. A nursing-led hypertension clinic at each site was utilized to facilitate prompt follow-up of patients who had a change in their antihypertensive regimen or were newly started on an antihypertensive. A new initiative in 2025 was a MyChart message sent to patients before an appointment reminding them to take their medications, bring their blood pressure medications and their blood pressure logs to the visit, and to not smoke or drink coffee before the visit. At MSMW, efforts to improve HTN control were continued, with a target of 75 percent of patients having a most recent BP <140/90. This target was increased from 70 percent over recent years as performance improved. Since initiation of this work, BP control has increased progressively from 63 percent in January 2022 to 74 percent by the end of 2025. All three practice sites demonstrated improvement over the past two years and remain on track to achieve the 75 percent target. MSMW’s four-phase HTN strategy, developed and implemented in 2022, was sustained through 2025 with several enhancements, including the addition of new Epic-based tools and expanded care team engagement.

Annual Quality and Patient Safety Report

Provider-focused interventions emphasized education, clinical decision support, and expanded monitoring options. Practice site champions reinforced best practices for BP measurement and documentation, including repeat measurements for elevated readings and incorporation of home BP values for both in-person and telehealth visits. Providers were encouraged to use telehealth for BP review and medication adjustments and to leverage interim visits with nurses and clinical pharmacists for closer monitoring. New tools strengthened this work, including the Hypertension Control Dashboard in Epic. The Primary Care Hypertension SmartSet was leveraged and a new HTN Best Practices Alert was added to the rooming workflow to prompt repeat BP measurements when initial readings were elevated. MA education remained a core component of the strategy, with continued emphasis on proper BP measurement techniques and standardized triage processes. Practice site champions and clinical supervisors provided ongoing education and reinforcement to support consistent implementation. Team-based workflows supported shared accountability for HTN management. Providers were encouraged to add a “last BP” column to Epic schedule views, enabling care teams to identify patients with uncontrolled BP during pre-session huddles and at the time of triage, and to focus efforts accordingly. Targeted outreach to patients with uncontrolled HTN was expanded to support timely follow-up and sustained BP control. Use of the Hypertension Control Dashboard facilitated identification of patients without upcoming appointments. Nurses and population health representatives conducted outreach to schedule follow-up visits, reinforce home BP monitoring, and support medication adherence, with MyChart messaging used when telephone outreach was unsuccessful. Providers also referred eligible patients to a remote BP monitoring program, which coordinated care with clinical pharmacists and patient care liaisons and provided ongoing telehealth-based management and maintenance. As a result of these combined efforts, HTN control increased from 72 percent at the beginning of 2025 to 74 percent by year-end, with a peak of 75 percent in September.

Controlling High Blood Pressure >140/90 76% 75% 74% 73% 72% 71% 70%

GMA

Annual Quality and Patient Safety Report

IMA

Dec 25

Nov 25

Oct 25

Sep 25

Aug 25

Jul 25

Jun 25

May 25

Apr 25

Mar 25

Feb 25

Jan 25

69%

UWS

Diabetes In 2025, IMA advanced its team-based model of care for diabetes management, incorporating certified diabetes educators and maintaining the dedicated high HbA1c clinic staffed by internal medicine interns. These efforts further supported patients in achieving improved glycemic control through comprehensive, multidisciplinary care. Since May 2022, IMA consistently remained below the target of less than 15 with uncontrolled HbA1c (>9 percent) and in 2024 set an ambitious new internal goal of reducing uncontrolled HbA1c rates to less than 10 percent, reflecting the continued commitment to delivering the highest quality of care. At MSMW, efforts included coordinated care with certified diabetes educators (CDEs) and clinical pharmacists on site to follow poorly controlled patients more closely and schedule regular office visits between provider visits. To qualify for remote patient monitoring, patients must have a diagnosis of type 2 diabetes and have two HbA1c values >8 in the last 12 months, or a new diagnosis of diabetes in the last three to six months with a HbA1c >8. They cannot be on a continuous glucose monitor. Like the remote BP monitoring program, the program consists of a multidisciplinary care team to help bridge the gap between provider office visits with education and monitoring. With the above efforts, as of the end of 2025, MSMW DGIM met the goal of <16 percent of uncontrolled diabetic patients with a last HbA1c of >9 at 15 percent. To improve the percentage of patients with uncontrolled diabetes at GMA, the Division, in collaboration with the MSHS Population Health Department, reached out to diabetic patients who had not been seen in over a year and provided them with a direct scheduling link to encourage them to return to care. The collaboration with the embedded clinical pharmacist who provides medication teaching and titration of medications also continued. At the 310 E 14th Street practice, daily huddles were conducted to discuss patients coming in that day and how to best manage their care (e.g., referral to care management, remote patient monitoring for diabetes, referral to clinical pharmacy). As of October 2025, GMA began using point of care HbA1c testing at 310 E 14th Street and 10 Union Square East sites with the goal of having more immediate data to make real-time medication adjustments. Although the rate of uncontrolled diabetes did drop to 16 percent in Q2, it rose again to 18 percent in Q4. A house staff quality improvement project dedicated to POCT HbA1c will start in 2026.

Annual Quality and Patient Safety Report

Diabetes Hemoglobin A1c Poor Control (HbA1c >9%)

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Jan 25

20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

UWS

Retinopathy Screen in Patients with Diabetes IMA continues to provide onsite diabetic eye exams using a retinal camera, significantly enhancing access to same-day screening during primary care visits. In 2025, IMA further strengthened its partnership with the Ophthalmology department, which now proactively contacts patients with abnormal retinal scans to schedule dilated eye exams and initiate treatment for diagnosed conditions, ensuring timely and comprehensive eye care. MSMW saw a dip in diabetic eye exam rates into 2024, prompting efforts to improve the rate of diabetic eye exams in 2025. This metric includes patients aged 18 to 75 with a diagnosis of diabetes. The eye exam should be done every two years if there is no diagnosis of retinopathy, and annually if a diagnosis of retinopathy is documented in the last three years. This differs from data recording in 2023, where the lookback period for retinopathy diagnosis was one year, compared to three years in 2024 and 2025. Additionally, external visit codes through Epic were narrowed to reflect accuracy. These changes explain the decrease in performance from end of 2023 to end of 2024, though it improved to 62 percent at the end of 2025. The continued efforts for this metric were multidisciplinary: MAs pending referrals to ophthalmology during triaging, providers placing referrals during both in-person and telehealth visits, and nurses completing direct outreach to patients. If a patient reported an ophthalmology visit outside of the system, the provider/MA can obtain the visit date and enter this into the Epic “health maintenance” tab to fulfill the gap. Medical directors also circulated updated lists of Mount Sinai ophthalmologists for referrals. To enhance the retinopathy screening rate for diabetic patients at GMA, the Division continued its bulk MyChart messaging outreach to patients every 6 months via MyChart to remind them to discuss screening at their upcoming visit and to bring in documentation if they already completed screening. The experience with MyChart messaging was not successful, thus in April 2025, a large-scale mailing campaign was conducted to encourage patients to screen or give their ophthalmologist a simple form to complete and fax back. Few forms were returned unfortunately and screening rates briefly increased to 68 percent in the second quarter but decreased back to 65 percent. In 2026, more outreach via telephone will be conducted to improve rates. Annual Quality and Patient Safety Report

Diabetes Eye Exam 100% 80% 60% 40% 20%

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UWS

Nephropathy Screening In 2025, IMA maintained its focus on nephropathy screening for patients with diabetes, building on the progress made in 2024. The workflow to obtain urine samples in clinic was simplified and is owned by nursing staff providing specimen cups for patients.

Diabetes: Medical Attention for Nephropathy at IMA 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50%

DM Nephropathy

Goal

Similarly, to increase the nephropathy screening rate at GMA, the Division continued bulk MyChart messages every six months advising patients who are due for screening, educating them on the need to screen, and encouraging them to walk in to complete testing. Additional interventions included pre-pending microalbumin orders for patients who were due to nudge providers to order microalbumin and to place urine cups in the check-in area to allow patients to collect urine samples while waiting to be roomed. The screening rate stayed consistently above 70 percent in 2025. In 2026, MAs will be trained to instruct patients to provide urine when rooming patients who are due for screening.

Annual Quality and Patient Safety Report

Rate of Retinopathy Screening in Patients Ages 18-75 with Diabetes 72 70 68 66 64 62 60

Q1 '24

Q2 '24

Q3 '24

Q4 '24

Q1 '25

Achieved

Q2 '25

Q3 '25

Q4 '25

Target

Cancer Screening Breast Cancer Screening The Division of General Medicine at MSMW continued to focus on breast cancer screening for women aged 40 to 74 and implemented several strategies to address gaps in screening. MAs routinely asked about mammograms during triage if the care gap was noted to be open. If needed, MAs pend the orders for the provider to sign during the visit. If the mammogram was done externally, MAs were asked to call outside radiology centers to obtain the report and record the completion date into the “health maintenance” tab. Epic also automatically captures mammograms completed at Mount Sinai and by outside claims in the “health maintenance” section. In addition, the existing mammogram van initiative continued at all practice sites. The van sets up outside each of the three practice sites once or twice a month. Providers have the capability to directly schedule their patients with the mammogram van. This allows for easier and faster access for patients to complete, and an alternative option for those with physical or social barriers preventing a visit to the radiology center. With these initiatives, the Division has an 80 percent breast cancer screening completion rate. Breast cancer screening remained a challenge for IMA in 2025. Walk-in services were reinstated in 2025, so the Division anticipates that rates will improve in 2026.

Breast Cancer Screening 84% 82% 80% 78% 76%

GMA

Annual Quality and Patient Safety Report

IMA

Dec 25

Nov 25

Oct 25

Sep 25

Aug 25

Jul 25

Jun 25

May 25

Apr 25

Mar 25

Feb 25

Jan 25

74%

UWS

Cervical Cancer Screening At IMA, cervical cancer screening rates significantly improved in 2025, driven by enhancements in reporting processes to align with current guidelines and expanded access to scheduling. These efforts have streamlined the identification of patients due for screening and made it easier for them to complete testing. The Division also worked with DTP to build out a bulk ticketed scheduling process by which patients due for screening are sent a link to schedule in masse. This should continue to drive improvement in 2026.

Cervical Cancer Screening at IMA 80% 75%

70% 65% 60%

Goal

Cervical Cancer Screening

Colorectal Cancer Screening To increase the rate of colorectal cancer screening, GMA had MAs pend Cologuard orders for patients due for screening and nurses made monthly reminder calls to patients with outstanding Cologuard orders. A screening rate of 76 percent for the last three quarters of 2025 was achieved. In 2024 into 2025, Internal Medicine resident physician Mako Koseki, MD, along with GMA faculty mentor Rui Jiang, MD, conducted a project to increase Cologuard order and completion rates through education of house staff in small group discussions, and of patients through educational posters, videos, and portal messaging. Patients were given the opportunity to respond directly to request a referral to gastroenterology for a colonoscopy or to receive a Cologuard kit. Cologuard completion rates improved from a preintervention median of 7 percent to 10 percent. Direct patient messaging had the most immediate impact, with 7 percent of patients responding, resulting in 16 screenings and a transient peak of 21 percent in monthly Cologuard completion. This project was published in BMJ Open Quality in October 2025. With the increase in Cologuard completion through MyChart messaging identified in this project, another group of house staff will be continuing bulk MyChart messaging patients, specifically those aged 45-59 as they have a higher rate of portal engagement. At MSMW, completion rates also continued to increase, from 71 percent in the beginning of 2023 to 80 percent as of the end of 2025, surpassing the goal of 72 percent, by collaborating with the Gastroenterology department to facilitate direct colonoscopy referrals. Colonoscopy referrals are directly placed by PCPs, bypassing the need for Gastroenterology consultation. Annual Quality and Patient Safety Report

After a direct referral is placed, the Gastroenterology scheduling coordinator reaches out to the patient to discuss and schedule the procedure. If a patient reports a colonoscopy performed at an outside facility, MAs were tasked with calling to retrieve the report and place the completion in the “health maintenance” tab and modify the screening interval to reflect. For patients who were hesitant or had barriers to colonoscopy, providers offered alternative screening options for average risk patients, including Cologuard and fecal occult blood testing.

Colorectal Cancer Screening 82% 80% 78% 76% 74% 72%

GMA

IMA

Dec 25

Nov 25

Oct 25

Sep 25

Aug 25

Jul 25

Jun 25

May 25

Apr 25

Mar 25

Feb 25

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70%

UWS

Depression Screening With regards to improving the rate of depression screening and follow-up, the medical office staff at GMA continued to perform Patient Health Questionnaire (PHQ)-2 screening on all patients during rooming and provided patients with a laminated PHQ-9 to complete if PHQ-2 screening was positive. Providers were reminded during huddles to ensure PHQ-9 questionnaires were completed and a plan documented. A multidisciplinary workflow was implemented at MSMW, including MAs, providers, and social workers, to improve depression screening. The team uses a workflow like the process used at GMA. Providers were also reminded to document the follow-up action taken if the PHQ-9 was positive (e.g., medication prescribed, therapy referral made, etc.) in the Epic flowsheet. If providers determine that a referral to a behavioral health (BH) specialist was indicated, the recently improved BH referral pathway facilitates this with SW engagement. Evidence has shown that patients are more likely to attend appointments and follow up with a psychiatrist if linkage to care occurs through their primary care provider (PCP). Therefore, the Division initiated a new BH referral pathway to utilize SW and CM teams to directly link patients with BH specialists. The objectives were: to increase timely access to BH care for those referred from their PCP, to provide patients with a liaison who can ensure adherence and engagement with BH providers, and to track successful referral connections and recommend areas where additional capacity is needed. The BH pathway starts with the PCP referring to SW or CM via telephone encounter or Epic referral. SW/CM then reviews options for therapy/psychiatry within Mount Sinai and reaches out to partner coordinators to help link patients to a BH provider. They also check in periodically

Annual Quality and Patient Safety Report

with patients to ensure continued engagement with the BH provider. SmartPhrase forms for SW documentation were developed to allow the population health team to track BH referrals and follow-up care. With the success of these workflows and pathways, the Division was at 84 percent compliance at the end of 2025.

Screening for Clinical Depression and Follow-up

GMA

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94% 92% 90% 88% 86% 84% 82% 80% 78%

UWS

Liver Fibrosis Screening MSMW also continued to focus on improving liver fibrosis screening among diabetic patients. Metabolic dysfunction-associated fatty liver disease (MAFLD) affects 25 percent of the population, and the incidence is higher in the diabetic population. Liver fibrosis is the most important predictor of clinical outcomes. The aim of this project was to increase fibrosis-4 (FIB4) score utilization to 10 percent of patients with type 2 diabetes. Of those with elevated FIB-4 scores, the goal is for 50 percent of patients to receive appropriate referrals for fibroscan or liver specialist consultation, based on the score. The FIB-4 Index for liver fibrosis is a noninvasive scoring system based on age and several laboratory tests, specifically liver enzymes and platelet count, which help to estimate the amount of scarring in the liver and the potential need for further investigation. A fibroscan is a quick and noninvasive diagnostic device using sound waves to assess liver stiffness and fibrosis. The stiffer the liver tissue is, the more severe fibrosis there is likely to be.

To increase engagement, providers were regularly reminded of the workflow. In patients with type 2 diabetes, FIB-4 scores should be calculated on an annual basis. During the visit, when diabetic patients are identified, the PCP can calculate the FIB-4 score utilizing the Epic Annual Quality and Patient Safety Report

SmartPhrase provided. This SmartPhrase automatically calculates the FIB-4 score and provides written recommendations based on the result. Providers then can place an Epic referral order for fibroscan or to a Liver specialist based on the score, as shown above. To increase accuracy and avoid unnecessary referrals, in 2024, this SmartPhrase was updated to reflect a score adjustment for patients aged 65 and older. The graph below illustrates the percentage of eligible patients screened utilizing the FIB-4 SmartPhrase. From 2023 into 2025, the Division met and continues to exceed the primary target of 10 percent.

For those with elevated FIB-4 scores, the percentage of patients who received a referral for further investigation was 63 percent, up from last year’s 43 percent and surpassing the goal of at least 50 percent. Lists of patients who are indicated for a referral to fibroscan or to a Liver specialist based on their FIB-4 score is generated, and coordinators assist in further patient outreach, both by phone call and arranging follow-up appointments with providers. Templated messages were created and distributed to both coordinators and providers, which can be sent to eligible patients via MyChart to increase engagement and awareness.

Annual Quality and Patient Safety Report

When looking at the results of the fibroscans completed on the pie chart below, about 23 percent of patients were diagnosed with some level of fibrosis. Without the FIB-4 score, this may not have otherwise been diagnosed or may have been found at a more advanced stage. This not only helps to identify liver fibrosis earlier and potentially minimize progression but also allows providers to connect patients to a liver specialist in a timelier manner.

Moreover, to further illustrate the importance and utility of FIB-4 scoring and fibrosis screening in diabetic patients, these findings were presented at the American Association for the Study of Liver Diseases (AASLD) during the 2025 conference. This was a joint effort between the departments of Gastroenterology and General Internal Medicine.

Annual Quality and Patient Safety Report

GMA also participated in this multisite project and compared using a SmartPhrase during patient care to calculate a FIB-4 score to provide guidance on further referrals to hepatology versus providing a list of calculated FIB-4 scores to primary care doctors, alerting them to which patients required referrals. Backend FIB-4 calculation resulted in a 100 percent screening rate versus 16 percent provider-driven, but significantly higher rates of referrals were given and completed among patients screened by providers (p<.0001). A systemwide dashboard to go live in January 2026 will include General Medicine and Endocrinology outpatient clinics. Additional Quality Projects At MSMW, medical residents engaged in a project aimed at increasing hepatitis B screening rates. Screening rates were at 15 percent pre-intervention despite having a practice alert embedded in the EMR. The house staff conducted brief educational sessions, which resulted in a transient increase in screening rate to 29 percent immediately after education; however, the rate dropped to 18 percent after 6 months, reinforcing the need for continuous education. This project was selected as an oral presentation at the DOM Grand Rounds Annual Scholars Day, part of the annual Mount Sinai Morningside/West Internal Medicine Residency Research Week in May 2025. Improving Naloxone Prescribing in Patients at Risk of Overdose To increase the presence of naloxone in patients at risk of overdose, Dr. Eric Kutscher, an IMA and REACH faculty, and Gary Gravesandy, a fourth-year medical student, implemented a BPA in July 2024. The BPA recommends an emergency naloxone kit to patients at high risk of opioid overdose, defined as history of opioid overdose, prior administration of naloxone during a visit or admission, diagnosis of opioid use disorder (not in remission), a recent prescription for an opioid medication, or a recent urine toxicology test positive for opiates or stimulants. Data collection is ongoing, and this project will continue in 2026.

Annual Quality and Patient Safety Report

Improving the Quality of Clinician Documentation in Epic: Problem-Based Charting In January 2024, the IMA faculty, Drs. Eric Kutscher, Doug Halket, Cary Blum, Alison Koransky, and Mary Fishman, and ambulatory chief resident Dr. Fiona Desland received a $50,000 grant from the Office of Well-Being and Resilience focused on improving clinic documentation and efficiency. In July 2024, all 160+ residents transitioned to problem-based charting and use of the standardized note template and orders preference list. Between Q1 of 2024 and Q1 of 2025, IMA residents saved an average of 19.1 minutes on charting per appointment. Time in the EHR outside of scheduled hours also decreased by 26.6 minutes per day. Copy and pasted text per note decreased by two thirds (23 percent to 8 percent) and note length decreased by 31 percent, or 2,660 characters. Smart Screening: Uncovering Cost Savings in Abdominal Aortic Aneurysm Detection At MSMW, the Division sought to improve completion rates of abdominal aortic aneurysm (AAA) screening in men aged 65-75 with a history of tobacco use using provider education and guidance in the EMR. AAA screening was added to the “care gap” and “health maintenance” tab in Epic for eligible patients, further increasing provider engagement. Nurses also conducted outreach to patients with incomplete screening via telephone and MyChart message scripts were created for convenience and standardization. Dr. Martin Arron, Dr. Martin Garcia, and Dr. Fernando Carnavali investigated potential cost savings involved with identifying patients who already had prior incidental imaging done. This work was presented at the 2025 Society of General Internal Medicine (SGIM) meeting.

Annual Quality and Patient Safety Report

The team determined how many eligible patients completed recommended AAA ultrasound screening and how many had prior imaging—such as CT, MRI, or other studies—that incidentally but adequately visualized the abdominal aorta. Incorporating these incidental findings substantially increased the effective screening rate from 14 percent to 33 percent. Among the 812 eligible patients, 110 completed screening ultrasounds and an additional 178 had adequate incidental imaging, revealing a significant opportunity to avoid redundant testing. The cost analysis, based on Medicare reimbursement rates, suggests that avoiding unnecessary ultrasounds could save more than $21,000 across the four practices (including Harlem Health Center) and approximately $174 million nationally. Statin Use in Patients with Cardiovascular Disease and/or Diabetes Another focus for the Division at MSMW was a newly added metric: statin use in CVD and/or diabetes. The target goal for this metric is for 83 percent of eligible patients to be marked as actively taking or have received a prescription for statin therapy during the measurement period. This metric includes all patients between the ages of 21 and 75 who either have a diagnosis of atherosclerotic cardiovascular disease (ASCVD), familial hypercholesterolemia, or a low-density lipoprotein cholesterol (LDL-C) level at or above 190. It also includes patients aged 40 to 75 with a diagnosis of diabetes. For this initiative, the Division focused on provider awareness and engagement. Providers were routinely reminded of evidence-based recommendation criteria for statin therapy as listed above. In addition, providers were updated on how the metric is met and certain exclusion criteria. These exclusion criteria include any patients who are ordered for a PCSK-9 inhibitor, have a diagnosis of end-stage renal disease or rhabdomyolysis during the measurement period, are receiving hospice/palliative care, or are pregnant or breastfeeding. Additionally, any diagnosis of statin-associated muscle symptoms or any patients with a listed statin allergy are excluded. To further engage and remind providers, in 2024, the statin metric was added to the “care gap” and “health maintenance” tab in Epic for those who are eligible. Throughout 2025, the accuracy of the data improved. One example of how this was done was to more accurately identify statin intolerance in the chart and remove ineligible patients from the metric by updating the exclusion diagnosis codes. The Division saw a large improvement in this metric, increasing from 70 percent at the end of 2023 to 78 percent at the end of 2025. With the above efforts, the Division will continue to improve in 2026.

Percent Compliant

UWS: Statin Use in Pts w/ CVD + DM in 2025

83% 76%

77%

78%

77%

78%

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Annual Quality and Patient Safety Report

Improved TDaP Vaccination Rates MSMW also prioritized improving TDaP vaccination rates in response to rising pertussis cases over the past several years. This initiative centered on a coordinated outreach strategy with a target of increasing vaccination rates by at least 3 percent across all Upper West Side practices within six months of launch. During Q1 2025, teams engaged providers and developed both MyChart and telephone outreach workflows. Initial MyChart messaging began in April 2025 (Q2), followed by mailed letters and phone outreach in July 2025 (Q3). A sample MyChart SmartPhrase message is shown below.

By early Q4 (October 2025), data analysis demonstrated clear improvement: TDaP vaccination rates rose from 48.5 percent of eligible patients in April to nearly 52.5 percent in October, exceeding the six-month goal. Building on this momentum, the Division plans to continue outreach efforts into 2026 with the aim of achieving at least a 6 percent increase in TDaP vaccination rates within the first 12 months of the initiative.

Annual Quality and Patient Safety Report

Hospital Medicine

Mount Sinai Brooklyn Throughout 2025, the Mount Sinai Brooklyn Department of Medicine prioritized quality improvement through structured, physician-led initiatives focused on reducing length of stay (LOS) and preventing avoidable readmissions. Hospitalists were actively engaged in quality improvement projects and multidisciplinary committees, working collaboratively with partners across the hospital to improve care delivery processes and patient outcomes. These efforts emphasized coordination, early planning, and standardized workflows to optimize inpatient care and transitions beyond discharge.

Length of Stay LOS was recognized as a key indicator of care efficiency, safety, and hospital throughput. At MSB, LOS was viewed not merely as a metric, but as a reflection of how effectively inpatient teams coordinated care, anticipated discharge needs, and managed patient flow. Shorter hospital stays were associated with fewer complications, improved patient experience, stronger hospital operations, and better alignment with patient expectations regarding recovery and discharge timing.

Annual Quality and Patient Safety Report

The Department of Medicine implemented several coordinated strategies to reduce LOS. These included daily interdisciplinary rounds to identify and address barriers to discharge early in the hospitalization and pre-discharge planning beginning at the time of admission. A Discharge Before Noon initiative was introduced to improve throughput and optimize bed availability. In addition, teams focused on thoughtful coordination of consults to avoid unnecessary delays and prioritized outpatient diagnostic testing when clinically appropriate, thereby limiting prolonged inpatient stays. These efforts resulted in measurable reductions in LOS across medicine service lines without a corresponding increase in readmissions. Among all medicine patients at MSB, LOS decreased from 7.3 days in both 2023 and 2024 to 6.8 days in 2025. Hospitalist-managed patients demonstrated continued improvement, with LOS declining from 6.4 days in 2023 to 5.3 days in 2025 (O/E 1.15), outperforming the voluntary sector by 21 percent (5.3 vs. 6.7). These improvements were associated with enhanced patient experience and improved emergency department throughput, supporting both quality and operational goals. Readmissions Readmissions remained a complex quality challenge due to contributing factors extending beyond the inpatient stay. While patients were often clinically stabilized at discharge, gaps in transitions of care, follow-up, education, and social support frequently contributed to return visits. In response, MSB adopted a physician-led, multidisciplinary approach focused on improving post-discharge processes and continuity of care. The MSB Readmission Committee was chaired by Dr. Christopher Maston and organized into disease-specific subcommittees led by physician champions. The committee focused on structured discharge planning, timely outpatient follow-up, patient education, and early identification of patients at high risk for readmission. This framework supported targeted process improvement, emphasizing actionable interventions tailored to specific conditions rather than administrative burden. Pneumonia The pneumonia subcommittee, led by Dr. Nabeeh Hauter, focused on improving adherence to evidence-based order sets and antibiotic stewardship practices. Interventions emphasized appropriate antibiotic selection and transition, elderly- and skilled nursing facility-focused discharge planning, vaccination coordination, and outpatient follow-up. These efforts were supported by staff education and standardization of pneumonia care pathways. Chronic Obstructive Pulmonary Disease (COPD) Under the leadership of Dr. Madiha Rabbani, COPD initiatives included implementation of inpatient care pathways, smoking cessation counseling, inhaler technique education, and coordinated pulmonary and primary care follow-up supported by transitions-of-care (TOC) outreach. The 2025 action plan outlined monthly multidisciplinary meetings involving nursing leadership, respiratory therapy, pharmacy, and medicine providers. Additional interventions included daily review of COPD admissions by a designated physician assistant, pharmacy-led meds-to-beds services, in-hospital spirometry to support diagnostic accuracy, and standardized inhaler education with spacers for inhalers provided on all inpatient units. Annual Quality and Patient Safety Report

Congestive Heart Failure (CHF) and Acute Myocardial Infarction (AMI) Led by Dr. Hewitt, the CHF and AMI subcommittee prioritized cardiology follow-up within seven days of discharge, TOCC phone calls within 72 hours, and comprehensive medication reconciliation. These measures aimed to reduce readmissions through early outpatient engagement and improved adherence to evidence-based management strategies. Stroke The stroke subcommittee, led by Dr. Rudolph, focused on discharge medication adherence, neurology appointments scheduled prior to discharge, and early rehabilitation planning. These interventions were designed to support recovery, reduce complications, and minimize avoidable readmissions. Sepsis The sepsis subcommittee, led by Dr. Radfan Gazali, addressed the elevated risk of readmission among sepsis survivors. Interventions included enhanced discharge education, seven-day outpatient follow-up, and collaboration with local nursing homes. Integration with palliative care supported early goals-of-care discussions and hospice transitions for high-risk patients. MSB participated in the STOP Sepsis Collaborative, with standardized screening tools and Epic order sets in place. Hospitalists maintained a 7 percent mortality rate in sepsis through standardized bundles. Ongoing efforts focused on strengthening post-discharge follow-up and improving coordination with skilled nursing facilities to reduce readmission. MSB’s 30-day sepsis readmission rate decreased to 12.7 percent in 2025 year-to-date, exceeding the established 2025 target of 14.0 percent. System-Level Initiatives Several initiatives supported quality improvement across multiple conditions, including increased utilization of meds-to-beds services, improved primary care provider documentation through a pilot initiative, enhanced outpatient follow-up through telemedicine and transitions-of-care coordination, and implementation of improvement strategies through resident teams. These system-level approaches promoted standardized care delivery and sustainability of quality efforts.

Annual Quality and Patient Safety Report

The Mount Sinai Hospital The Division of Hospital Medicine (DHM) at The Mount Sinai Hospital (MSH) is active in many aspects of quality improvement and patient safety, including improving length of stay, reducing readmissions, safety in transitions of care, reducing hospital-acquired infections, and working to improve equity in care. MSH DHM is also part of the systemwide effort to expand the Mount Sinai Hospital at Home program and is proud to be a strong contributor to the enrollments in Hospitalization at Home and Rehabilitation at Home. The faculty are also active in multiple hospital-wide committees, including the MSH Root Cause Analysis Committee, MSH Clinical Review Committee, MSH Department of Medicine (DOM) Quality Improvement Committee, MSH Length of Stay/Readmissions Committee, MSHS Sepsis Committee, and the MSHS Pneumonia Committee. Length of Stay In 2025, DHM worked on several projects to improve length of stay (LOS). The Division has worked to balance the rising census with efficient care coordination and to align more closely with hospital-wide efforts towards reducing LOS in 2025. Ongoing initiatives to target reduced LOS include a re-design of the long-stay review meetings, referrals to the Discharge Acceleration at Sinai Hospital (DASH) program and continued use of the “Phone-A-Friend” Program, through which experienced hospitalists provide real-time guidance and mentorship to faculty caring for complex patients. Long-Stay Review Redesign Traditionally, long-stay review meetings for DHM patients were primarily focused on social barriers to discharge, such as lack of insurance/inadequate insurance coverage to meet discharge needs, complex care needs that make facility placement difficult, and other social or behavioral health issues. Staff involved felt that this approach overlooked opportunities to prepare medically active patients earlier in their hospitalization. To improve this process, DHM collaborated with social work and case management to identify common challenges that cause Annual Quality and Patient Safety Report

delays in discharge planning such as delirium (specifically requiring safety observation or restraints), patient/family delay in decision-making, delays in clinical team consensus on the treatment plan, and concern for goals-of-care mismatch or medical futility. Front-line social workers and case managers were empowered to escalate cases to the long-stay review committee for further review and discussion, even if the patient did not meet the long-stay LOS criteria. This work contributed to the LOS reduction seen in 2025. Additional LOS Reduction Efforts In addition to the long-stay redesign, other efforts to improve LOS included re-emphasis on interdisciplinary rounds structure and attendance, reorganization of Epic workflows around DASH and social work, and work at the hospital and system level to create expedient and centralized workflows for patients planned for discharge to a post-acute-care facility. Other active initiatives include those to improve interhospital transfers in terms of clear need for transfer and to encourage round-trip transfers whenever possible, to understand and resolve barriers to discharge for patients who undergo tracheostomy during hospitalization, and to streamline the coordination of bedside procedures for hospitalized patients through the Hospital Medicine Procedural Service. The Division has seen a trend towards improvement in the overall LOS and in the proportion of patients with long length of stay >15 and 30 days over the past year with a combination of these interventions. (See graphs below.) MSH Hospital Medicine Service Length of Stay - 2025 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00

1.37 8.64

1.36 8.21

1.42

1.45

9.47

1.60 1.27 8.02

1.31 8.20

1.30 8.43

8.29

1.14

7.42

7.35

1.20 1.40 1.20

1.17

1.14

7.15

7.19 7.60 1.00 0.80 0.60

0.40 0.20 0.00

ALOS

Annual Quality and Patient Safety Report

1.25

LOS O/E

MSH Hospital Medicine Long vs. Short Length of Stay Patient Encounters 25.00% 29.09% 26.73% 24.41% 25.73% 25.58% 24.20% 28.89% 27.29% 28.57% 29.74% 30.04%

70.04% 66.37% 66.58% 70.58% 70.57% 70.05% 71.62% 68.28% 68.86% 68.53% 67.33% 66.67% 4.96%

4.53%

6.68%

5.01%

3.69%

Long Stay % of Total

4.37%

4.18%

Mid Stay % of Total

2.82%

3.85%

2.90%

2.93%

3.29%

Short Stay % of Total

Daily Long Stay Census and Percent of Overall Census on Hospital Medicine, 2025 25.00%

45 40

20.00%

35 30

15.00%

25 20

10.00%

5.00%

5 0

PERCENT OF DHM CENSUS

DAILY LONG STAY CENSUS

0.00%

DATE MSH Long Stay Census

MSH % Long Stay

Linear (MSH % Long Stay)

Readmissions DHM continued to work on transitions of care, with the goal of improving readmissions. The readmissions rate was 16 percent in 2025, as compared to 15 percent in 2024. There has been active work with several divisions, including Pulmonology and Cardiology, to improve the readmissions rates related to pneumonia, chronic obstructive pulmonary disease, and congestive heart failure. DHM also provides a lecture series to the internal medicine categorical interns during ambulatory blocks focused on improving communication and coordination of care during the transition that occurs at discharge from the hospital.

Annual Quality and Patient Safety Report

Throughout 2025, there was an increased effort to re-assess processes related to sepsis readmissions and heart failure readmissions. DHM has collaborated with the Heart Failure nursing program to create better connection and alignment among inpatient teams and the Heart Failure nursing and education resources, as well as follow-up resources. This collaboration will continue into 2026. Improving Diagnostic Excellence at Mount Sinai Hospital MSH is proud to be a site participant in the Achieving Diagnostic Excellence Through Prevention and Teamwork (ADEPT) study. This 16-site AHRQ-funded study is a multicenter, real-world quality and safety program that utilizes retrospective and concurrent case review through an interrupted time-series technique to evaluate rates of error among patient cases where an ICU transfer, rapid response call, or death occurred. Ten cases per month are randomized and adjudicated and then reviewed using a two-clinician review process. Six reviewers at MSH collaborate in these reviews, and by December 2025 had reviewed close to 100 retrospective cases and approximately 185 concurrent cases, for a total of approximately 570 individual case reviews. In 2025, the MSH ADEPT team also launched an intervention called the “Diagnostic Cross-Check,” which was designed to improve real-time near-peer second opinion on challenging cases. The results of this intervention will be evaluated in 2026, and the group plans to form a Diagnostic Excellence Committee to carry forward the work started as part of the grant. Central Line-Associated Bloodstream Infections (CLABSI) DHM has taken an active role in interdisciplinary work to improve rates of central lineassociated bloodstream infection (CLABSI) at MSH. We have seen a significant improvement in the rate of CLABSI on the medicine service at MSH in 2025 as compared to 2024, with an SIR improvement from 3.53 to 1.49 for non-MBI CLABSI. In 2024, DHM examined 24 CLABSIs attributed to Medicine and found that 38 percent were on TPN, 46 percent had LOS > 30 days, 58 percent had pressure injuries, and 88 percent had at least one of these clinical features. Based on this data, a QI project was undertaken to identify patients on the medicine service with a central line and either TPN, pressure injury, or LOS > 30 days. A list of these patients at high risk for CLABSI was generated on a weekly basis and the QI team organized a virtual huddle on these patients with the clinical team. Through Epic chat groups, the team was asked to review best practices in central line care including line necessity, the integrity of the dressing, the appearance of the line insertion site, and whether there was opportunity to convert IV medications to oral formulation. The team was also prompted on the indication for parenteral nutrition and wound care. From July 2025 to December 2025, there were 207 virtual huddles completed in which there were four opportunities identified to de-escalate lines and seven opportunities to convert IV medications to oral. All lines were reported to have intact dressing. On review of the CLABSIs on medicine units (10W, 9W, KCC4S/5S, KCC5N), the number of CLABSIs decreased from 19 in 2024 to eight in 2025 (see graph below).

Annual Quality and Patient Safety Report

2024-2025 CLABSI Rates on MSH Medicine Units (10W, 9W, KCC4S/5S, KCC5N) 4

1 1

0 Jan

Feb

Mar

Apr

May

June

1 1

July

Aug

Sept

Oct

2024

Nov

Dec

2025

Student High-Value Care Curriculum The Student High-Value Care Curriculum is an active part of the DHM Quality Improvement efforts. In the past years, the curriculum was expanded to create partnerships with several other divisions and departments. This curriculum mobilizes and empowers groups of medical students, master’s students, and nursing students to work together to solve real-world challenges and to decrease overuse of materials and services in the hospital. In the 2024-2025 academic year, the curriculum sponsored two projects. The first was a project targeting improved sleep for patients on the medicine service at MSH. The second was a collaboration with the Division of Infectious Diseases designed to encourage providers to use oral antibiotics rather than intravenous antibiotics for patients with microbiologic data proving susceptibility. The student leaders for the curriculum also took part in the national Students & Trainees Advocating for Resource Stewardship (STARS) program.

Annual Quality and Patient Safety Report

Mount Sinai Morningside Length of Stay Since mid-2024, the Division of Hospital Medicine at Mount Sinai Morningside successfully navigated the merger of residency programs and the closure of Mount Sinai Beth Israel, including the integration of its hospitalists, while maintaining and improving LOS metrics. Despite also caring for a higher volume of patients with higher expected LOS and CMI than in 2024, an improvement in ALOS, LOS O/E, and a reduction in percentage of long-stay cases were observed. Since 2022, the overall trajectory of LOS for hospital medicine continues to improve through multidisciplinary efforts.

In collaboration with the Division of Endocrinology, a new initiative to reduce the length of stay for patients admitted with a primary diagnosis of diabetes is anticipated to launch in Q1 2026. Baseline data from 2024 suggests a current average LOS of 5.03 days with an O/E of 1.32. The aim is to reduce LOS by 0.5 days by standardizing and streamlining clinical workflows with early endocrinology consultation, standardized glycemic targets for discharge,

Annual Quality and Patient Safety Report

and an emphasis on communication between primary and consulting teams, especially around discharge timing. Consult triggers and best practices for the care of inpatients with diabetes will be socialized among the primary teams and house staff. A bedside “nurse nudge” component to assist with consult trigger adherence will also be trialed. Improving glycemic control in inpatients will align with CMS’s new quality reporting mandate for severe hyperglycemia and hypoglycemia. Ongoing work by the systemwide pneumonia committee (comprising hospital medicine leads from each campus) focuses on optimizing and standardizing pneumonia care and, relatedly, pneumonia-specific LOS, readmissions, and mortality. In collaboration with Agile MD, the system pneumonia committee is working to develop a clinical decision support pathway within Epic for pneumonia that would standardize care across the system, improving efficiency, and patient outcomes. The pathway is anticipated to launch in Q1 2026. Patient Safety In late 2025, the divisions of hospital medicine across campuses (MSH, MSM, and MSW) collaborated with Addiction Medicine, Pharmacy, and IT to address safety concerns involving patients with alcohol use disorder who were initiated on naltrexone while taking chronic opioids for other conditions, which resulted in acute, severe opioid withdrawal. Improving naltrexone safety began with expedited implementation of an Epic hard stop (see image) when a provider attempts to order naltrexone for a patient with an active opioid order. Next steps include developing automated identification of patients without an active opioid order who may have received opioids within the preceding seven days. Educational sessions are planned, and the team will continue to monitor the impact of their efforts on these events.

In late 2025, the Division also began work on a safety initiative involving patients admitted with known severe pulmonary arterial hypertension. Following an adverse outcome earlier in the

Annual Quality and Patient Safety Report

year, it was identified that there is no standardized workflow to manage these complex patients on the west side. As such, a multidisciplinary and cross-campus work group to develop a Workflow for Patients with Severe Pulmonary Artery Hypertension (PAH) admitted to Medicine was formed. The group will define consult triggers, ensure reliable access to PAH expertise, develop a protocol to ensure timely access to specialty medications, and leverage IT to support adherence to the workflow. Tentative metrics will include time to consultation, time to resume home PAH medications, escalation of care rate, and readmissions. Attending Escalation Initiative A formal escalation policy directs residents to alert supervising attendings when specific clinical changes occur; however, the extent to which this policy is followed remains unclear. Within the last year, three of the 12 peer learning sessions at MSM identified escalation of care issues as contributory factors. A review of RRTs (rapid responses) from March-April and July-September 2025 found at least five cases a month where a delay in escalation of care to the day attending or nocturnist took place. A baseline survey of 140 PGY-2 and PGY-3 internal medicine residents was conducted to quantify escalation policy and behaviors. Among 69 respondents (approximately 50 percent response rate), fewer than half reported feeling very comfortable escalating acute clinical status changes, and about three-quarters reported that they rarely or never contacted an attending in evening hours. Only 20 percent of residents felt very comfortable reaching out to nocturnists with patient-related concerns (43 percent replied, “not comfortable” and 36 percent were “somewhat comfortable”). To address this issue, an evening check-in between the senior resident and hospitalist between 6 and 8 pm was instituted to provide an opportunity to briefly discuss new admissions and space to raise concerns about other patients. Implementation of a nightly check-in with the supervising nocturnist is the next intervention currently underway. Preliminary review of rapid response activations since implementation of the evening check-in in October 2025 has shown, on average, two to four cases a month attributed to delays in escalation of care. Further work will focus on reinforcement of evening check-in as well as institution of the nightly check-in and post-intervention survey with the residents. Additional Quality Initiative Finally, in late 2025, the Division supported the launch of a resident-led ultrasound (US)– guided peripheral IV (PIV) initiative for teaching teams at MSM and MSW. The responsibility for placing US-guided PIVs in patients with difficult vascular access often falls to residents, and both the placement process and the need to solicit assistance were identified as contributors to decreased quality of work life through an anonymous survey. Through this initiative, an Epic chat group was created to streamline peer-to-peer requests for assistance with US-guided PIV placement (see image). Participants are additionally supported by the Vascular Access Team and by simulation-based training to develop or refresh the skills required for US-guided PIV placement. The next steps planned include follow-up assessment of participants’ quality-of-life scores and evaluation of the team’s overall impact, including line placement success rates, effects on vascular access team consult volume, and complication rates.

Annual Quality and Patient Safety Report

Mount Sinai South Nassau Throughout 2025, Mount Sinai South Nassau (MSSN) continued its focused efforts on quality improvement, with specific emphasis on length of stay (LOS) optimization and pneumonia care standardization. These efforts were led collaboratively by medicine leadership, hospitalists, voluntary attendings, medical advisors, and case management. Length of Stay MSSN tracked LOS metrics across 2023, 2024, and 2025 year-to-date, monitoring both average LOS and observed-to-expected (O/E) performance. The data demonstrated consistent improvement, with the Division maintaining an O/E ratio below 1 at 0.88 and achieving an overall LOS under 5 days for the Hospitalist group (see table below). Of note, the non-hospitalist group is comprised of voluntary physicians who primarily admit nursing home patients at MSSN. Systemwide comparisons further highlight the Division’s strong performance relative to peer hospitals across the Mount Sinai Health System.

Annual Quality and Patient Safety Report

Department of Medicine Yearly Length of Stay Trends: MSSN Best in System

To improve length of stay, the Department implemented coordinated LOS initiatives led jointly by Medicine, Hospitalists, and Case Management, with a strong emphasis on collaboration and standardized workflows. Daily interdisciplinary rounds, close communication with case management, and focused discharge coordination helped proactively address barriers to timely discharge. Leadership reinforced accountability through regular meetings and review of LOS, O/E performance, and real-time analytics dashboards. Hospitalists were evaluated based on quality metrics, including length of stay (LOS), to align clinical practice with organizational priorities. Routine team huddles supported adherence to clinical guidelines and promoted efficient, consistent care throughout the hospitalization. Pneumonia Readmissions MSSN participated in the Mount Sinai Health System (MSHS) Pneumonia Care Standardization Initiative, led by the pneumonia team. This initiative focused on reviewing pneumonia admissions, LOS, readmissions, ED and observation data, demographic patterns, and care standardization metrics. These efforts led to a 12.6 percent readmission rate (O/E 1.05) in 2025 (January to November), a decrease from 15.7 percent in 2024. These efforts led to a significant reduction in the CMS value-based purchasing penalty. In 2025, MSSN managed a notably higher case volume compared with other hospitals in the system, including MSH. MSSN recorded 920 pneumonia cases during this period, compared with 560 at MSH, despite MSH being a significantly larger hospital. While the pneumonia case volume is greater, the readmission rate remains lower at 12.6 percent compared with 14.1 percent at MSH; in absolute numbers, this reflects 116 readmissions versus 79 at MSH.

Annual Quality and Patient Safety Report

Further analysis examined trends among different discharge groups, including routine discharges, home health care discharges, and skilled nursing facility (SNF) discharges. Surprisingly, readmission rates by discharge groups showed 7.8 percent for routine discharges (O/E 0.95) and 15.9 percent for patients discharged to home with home health care services. The readmission rate for SNF discharges was 18.9 percent (O/E 1.06). As SNF discharges decreased, MSSN saw an increase in home health care discharges. Despite improvements in readmission rates in 2025 from 2024 for patients discharged with home services (from 20.1 to 15.9 percent) and those discharged to SNF (from 21.7 to 18.9 percent), readmissions among these patients remained high, representing a significant improvement opportunity for 2026. To improve these rates, MSSN inpatient teams strengthened mobility programs and provided support with DME and home medications. Critical partnerships were emphasized across SNF, intermediate care, and home health care agencies in 2025. Local facilities associated with MSSN meet monthly during a post-acute-care collaboration to discuss relevant issues with post-discharge care, including education on services available through MSSN, like the follow-up COPD clinic and pulmonary rehabilitation. Facility‑level performance data demonstrated reductions in readmissions among several local SNFs, highlighting how critical strong partnerships are in reducing readmissions. These partnerships were presented as essential components for improving transitions of care and reducing readmissions and led to a decrease in readmissions from SNF and intermediatecare facilities from 40 percent in 2024 to 27 percent in 2025. SNF readmission rates showed notable improvement, decreasing from 21.7 percent in 2024 to 18.9 percent in 2025. Care Pathway Strengthening MSSN’s work throughout the year reflected significant progress in LOS management and pneumonia care standardization. Key accomplishments included achievement of LOS under five days, improvement in SNF readmission rates, and active engagement in systemwide initiatives aimed at optimizing pneumonia management. Standardizing pneumonia care pathways was essential to improving the quality, consistency, and outcomes of care for patients. These standardized pathways help ensure reliable, high-quality care delivery while improving patient safety and clinical outcomes. Two detailed pneumonia cases were presented to illustrate the positive impact of standardized care approaches: •

Case 1: An 83-year-old female with multiple comorbidities experienced multiple readmissions in 2024 but had no readmissions in 2025 due to improved team coordination and familiarity with her case.

•

Case 2: A 66-year-old male with COPD and pneumonia achieved improved outcomes following rapid COPD clinic follow‑up and pulmonology care coordination, with no subsequent readmissions.

Ongoing comprehensive action plans for pneumonia care improvement include: •

Weekly interdisciplinary readmission review meetings

•

Exploration of observation status opportunities in the ED

•

Pulmonary committee initiatives to identify barriers and recommend interventions

•

Staff education on updated CDC pneumococcal protocols

Annual Quality and Patient Safety Report

•

Vaccination encouragement efforts across influenza, RSV, COVID, and pneumococcal vaccines

•

Smoking cessation services

•

Meetings with Coding and Finance teams

•

Distribution of pneumonia educational pamphlets to all discharged patients

Diagnostic Stewardship Diagnostic stewardship was a key quality initiative at MSSN aimed at ensuring the appropriate use of diagnostic testing to support accurate clinical decision-making and reduce harm. In 2025, MSSN sought to optimize catheter use and promote appropriate ordering of urine and blood cultures. By focusing on reducing unnecessary testing and monitoring contamination rates, these initiatives supported improved patient safety, more reliable diagnoses, and responsible use of health care resources. Catheter usage has decreased since 2023, however, there was an increase in the Foley standardized utilization ratio in 2025 to 0.94 (see chart below). To reduce catheter days, the team focused on education and regular multidisciplinary meetings that included case reviews and ongoing reminders. Catheter use was consistently discussed at Grand Rounds and resident rounds to reinforce appropriate indications and timely removal.

Blood and urine cultures have continued to decrease from 2023 to 2025 (see below). Non-ED contamination rate remained low in 2025 and decreased from 1.5 percent in the third quarter to 1.2 percent in the fourth quarter of 2025.

In addition to these initiatives, a systemwide initiative was also implemented requiring abnormal urinalysis prior to obtaining a urine culture, supporting more judicious catheter-associated urinary tract infection testing. Prior to the implementation of the reflex urine culture, approximately 714 cultures were sent per month; after the implementation, that number decreased to 660 cultures per month.

Annual Quality and Patient Safety Report

Mount Sinai Queens In 2025, Mount Sinai Queens (MSQ) monitored standard inpatient quality metrics, including length of stay, 30‑day readmissions, and inpatient mortality, to assess performance and guide improvement efforts within the Division of Hospital Medicine (see table below). These measures provided a consistent framework for evaluating efficiency, care transitions, and patient outcomes across clinical service lines. Based on observed performance trends, MSQ undertook targeted quality improvement initiatives focused on length of stay reduction (from 5.6 days in 2024 to 5.2 days in 2025) and readmission prevention (from 12.1 percent in 2024 to 10.1 percent in 2025). These efforts emphasized care standardization, discharge planning, and transitions of care and are described in detail in the sections that follow.

Transitions of Care: Impact of Timing of Discharge Notice on Readmissions and LOS Mount Sinai Queens evaluated whether providing patients with advance notice of planned discharge influenced readmission rates or length of stay (LOS). Medicare regulations require hospitalized patients to receive the “Important Message from Medicare” (IMM) prior to discharge; however, limited evidence exists regarding the impact of earlier discharge notification on clinical outcomes. Annual Quality and Patient Safety Report

Beginning in November 2024, hospitalist teams focused on providing patients and caregivers with 24-48 hours’ notice of anticipated discharge for hospital stays exceeding two days. Providers were instructed to verbally communicate expected discharge timing and document this using the existing “Implement DC Plan” (IDP) order in the electronic medical record. Nursing staff then delivered the IMM or contacted caregivers when appropriate. Although prompted by Medicare requirements, the process was applied to both Medicare and non-Medicare patients, with compliance monitored and feedback provided through EMR audits. Analysis included patients with lengths of stay between 3 and 30 days who were discharged home with or without services. IDP utilization increased significantly from 78 percent in 2024 to 90 percent year-to-date in 2025 (p < 0.001). The timing of discharge notification also shifted, with increases in one and two day advance notice and a decrease in same day notification. When 2024 and 2025 data were combined, no differences were observed in readmission rates or LOS based on discharge notice timing (see tables below).

Overall, findings demonstrated that earlier discharge notification did not affect readmissions or LOS among patients discharged home despite the increased IDP rate. Future work was proposed to explore interdisciplinary workflows and patient communication strategies related to discharge planning. Pneumonia Care Standardization Initiative MSQ participated in the Mount Sinai Health System Pneumonia Care Standardization Initiative, which was led by Dr. Allegra Lee. The initiative focused on reviewing pneumonia admissions, length of stay, readmissions, and care standardization metrics to identify drivers of performance and target improvement opportunities. Using Tableau dashboards and internal data sources, MSQ reviewed system-level and local readmission trends, patterns of index pneumonia diagnoses versus readmission diagnoses, discharge unit and disposition, and timing of readmissions. Most readmissions occurred 15–30

Annual Quality and Patient Safety Report

days after discharge, followed by 8–14 days, with readmission lengths of stay most commonly ranging from 3 to 10 days. Days in acute care metrics were also reviewed to assess emergency department, observation, and inpatient utilization following pneumonia discharges. Case reviews identified several recurring themes, including a high prevalence of viral upper respiratory infections in January and February, challenges with post-discharge medication access, and readmissions among patients with significant comorbidities and complex clinical courses. Aspiration events, recurrent viral infections, and patient-driven treatment decisions were also noted contributors. Care standardization metrics demonstrated partial adoption of the pneumonia pathway, with additional analyses stratified by race, ethnicity, age, and gender to assess variation in outcomes and pathway use. Performance improvement efforts focused on maintaining pneumonia readmission performance, with a 30-day observed-to-expected readmission ratio of 0.98, below the target of 1.1. Pneumonia pathway utilization was 53.7 percent in July, with a goal of 60 percent. Interventions included provider education, onboarding integration, real-time pathway review, and participation in a system initiative to develop AI-supported pathway workflows, with efforts ongoing through December 2025. Targeted initiatives addressed aspiration prevention, resulting in improved identification of atrisk patients and increased use of appropriate aspiration precautions. Preventive care efforts focused on increasing influenza and pneumococcal vaccination rates, while smoking cessation initiatives aimed to improve use of pharmacotherapy at discharge for current smokers. Overall, the Pneumonia Care Standardization Initiative at MSQ emphasized systematic review of pneumonia outcomes, identification of readmission drivers, and focused improvement strategies targeting pathway utilization, aspiration prevention, documentation accuracy, vaccination uptake, and post-discharge risk reduction. Acute Osteomyelitis and Diabetic Foot Infection Pathway Mount Sinai Queens implemented a targeted length-of-stay (LOS) reduction initiative focused on patients admitted with acute osteomyelitis and diabetic foot infections. This work was conducted under the Department of Medicine’s LOS optimization efforts and centered on promoting earlier transition to oral antibiotic therapy and reducing reliance on peripherally inserted central catheters (PICC lines). A standardized acute osteomyelitis and diabetic foot infection order set was launched in Epic in March 2025. The order set incorporated updated recommendations for antibiotic selection and appropriate imaging. Active case review and feedback were provided to Infectious Diseases consultants to identify patients eligible for oral antibiotic therapy, with review informed by the OVIVA trial. In parallel, Epic alerts were implemented to notify providers when wound cultures demonstrated sensitivity to oral antibiotics. The primary goal of the initiative was to reduce length of stay by increasing the number of patients discharged on oral antibiotics and decreasing the use of PICC lines. Outcomes from this initiative demonstrated improvement in both LOS and device utilization. Median length of stay decreased by one full day following implementation of the pathway, and PICC line use was reduced by approximately 50 percent. These changes reflected a shift in Annual Quality and Patient Safety Report

clinical practice toward earlier oral therapy and fewer prolonged inpatient courses requiring intravenous access. Acute Osteomyelitis Project Outcomes

The table above summarizes key metrics before and after pathway implementation. In 2024, 223 patients were included, with 65 receiving a PICC line or midline (29 percent). Mean LOS was 8.77 days, with a median LOS of 8 days. In 2025, following pathway implementation, 303 patients were included, with 44 receiving a PICC line or midline (15 percent). Mean LOS was 9.31 days, while median LOS decreased to 7 days. These findings indicated a substantial reduction in PICC line utilization alongside an improvement in median length of stay following the introduction of the acute osteomyelitis pathway.

Mount Sinai West Advancing Care Through Collaboration: A Pharmacy Technician Education Program to Improve Medication Reconciliation Medication reconciliation is critical to patient safety but it is one of the most time-consuming processes in hospital medicine. At MSW, in August of 2025, medication reconciliation was completed in only 49.4 percent of patients within 24 hours of admission, despite strong provider consensus on its relevance in providing safe patient care. A project led by Dr. Foram Parikh aimed to improve the timeliness of admission medication reconciliation by integrating

Annual Quality and Patient Safety Report

pharmacy technicians into the workflow and reducing time spent by providers in obtaining medication history. An internal medication history training program aligned with the Pharmacy Technician Credentialing Board (PTCB) requirements was developed at Mount Sinai West. Four pharmacy technicians were selected to participate in a blended curriculum that combined online education with structured inpatient clinical rotations. During these rotations, technicians conducted realtime medication history collection under pharmacist supervision, gaining direct patient care experience while supporting inpatient admissions. Following integration of pharmacy technicians into the medication reconciliation workflow, completion rates within 24 hours of admission improved steadily from a baseline of 49.4 percent in August to 52.9 percent in September, 54.1 percent in October, 60.7 percent in November, and 61.0 percent in December 2025. As the technician experience increased, efficiency also improved. Average time spent per medication history decreased from 99 minutes in October to 78 minutes in November and 64 minutes in December 2025. Integrating trained pharmacy technicians into the inpatient admissions process led to a modest improvement in medication reconciliation timeliness. However, several key barriers such as restricted technician hours, lack of weekend coverage, and heavy reliance on a single supervising pharmacist to ensure medication accuracy may have impacted the results. To sustain and expand this work beyond the grant period, the Division will train additional technicians and integrate the service more fully with the pharmacy operations leadership to support broader implementation across sites. The Office of Well-Being and Resilience (OWBR) funded this project through the Faculty Reduce Grant as an interdisciplinary initiative to strengthen patient safety, reduce provider burnout, and promote wellness among hospitalists, advanced care providers, and house staff, while also expanding career advancement opportunities for pharmacy technicians.

Annual Quality and Patient Safety Report

Reducing Delays in Diagnostic Paracentesis and Expanding Procedural Competency Among Residents and Hospitalists Delay in diagnostic paracentesis for inpatients with cirrhosis has been shown to increase the risk of acute kidney injury, ICU transfer, and inpatient mortality. One of the barriers to performing early diagnostic paracentesis is the lack of certified providers. Procedural certification is no longer a requirement of internal medicine residency programs, and many hospitalists lack experience in bedside procedures. To improve the timeliness of diagnostic paracentesis, a team led by Drs. Vasundhara Singh and Lance Maresky, along with internal medicine resident Dr. Joseph Abraham, created a secure chat-based paracentesis group that included certified proceduralists and trainees seeking certification across Mount Sinai Morningside and West. When a patient requires paracentesis, the admitting team posts clinical details in the secure chat, allowing for rapid identification and pairing of a certified supervisor and learner. A comprehensive protocol was developed prior to implementation to define eligibility, training requirements, documentation standards, billing considerations, and escalation pathways for complications. Educational resources are readily available, and procedures and certifications are tracked through the New Innovations platform. In the first 111 days following implementation, an average of 4.5 paracentesis requests per week were initiated through the chat, with a mean response time of 1.4 minutes to identify a proceduralist-trainee dyad. Most notably, the number of certified proceduralists who can perform paracentesis more than doubled, increasing from 16 to 34 within four months. Qualitative feedback demonstrated improved resident confidence, increased access to equitable procedural opportunities, and expedited patient care during high-volume clinical periods. Overall, the abstract describing this scalable intervention to improve procedural capacity and training while streamlining workflow and reducing barriers to timely paracentesis was published in the January 2026 edition of The Hospitalist.

Annual Quality and Patient Safety Report

Reimagining Post-Acute-Care Transitions: Increasing Home Discharges to Reduce Length of Stay and Improve Throughput at Mount Sinai Morningside and West Length of stay reduction is a focus for the Mount Sinai Health System, with several initiatives underway to improve care progression and throughput. Needing post-acute-care services after hospitalization can cause a delay in discharge due to prior payor authorization requirements and the coordination of bed availability with facilities. Additionally, recovery at home has shown to have better patient outcomes when appropriate. This project, led by Dr. Shantheri Shenoy at MSMW in collaboration with the interdisciplinary care management team and physical therapists, focused on patients with AMPAC (Activity Measure for Post-Acute Care) scores greater than 18 being recommended for sub-acute rehabilitation (SAR) or skilled nursing facility discharges. AMPAC has been shown to have high predictive validity, with scores greater than 18 being associated with better recovery at home. A shared document called “Let’s Go Home Watchlist” was created and shared with interdisciplinary teams. A dedicated reviewer, from the population health team who is also a trained physical therapist, screened electronic medical records daily to identify patients with AMPAC scores greater than 18 and recommended them for sub-acute rehab on discharge. If deemed appropriate for home discharge by the reviewer, patients were added to the watchlist before interdisciplinary rounds (IDR) in the morning. Case Management, Social Work, Physical Therapy, and Unit Medical Directors were notified by email of the additions to the list before 10:30 am interdisciplinary rounds. Alternate discharge options were discussed during IDR. If the front-line team agreed, patients were discharged home with appropriate resources. Additional interventions included educational sessions to increase awareness and Epic enhancements that make AMPAC readily accessible in the PT recommendation column. From March to December 2025, a total of 156 patients were placed on the watchlist with an average conversion rate to home of 46 percent at Mount Sinai Morningside and 55 percent at Mount Sinai West. The total number of excess days saved from conversion for both sites was 476 with an estimated direct cost saving of $412,893.

Annual Quality and Patient Safety Report

Data source: “Let’s Go Home Watchlist” and Epic

Data sources: Vizient, Tableau, and hospital financial data The 30-day emergency department (ED) visit rate and 30-day readmission rate for patients discharged to SAR and home were identified as balance measures for this initiative. Although the readmission and ED visit rates were higher among patients discharged home, the differences were not statistically significant. Fall count was also measured for patients discharged to home and SAR. Fall count was defined as documented falls listed as the reason for admission or falls documented in physical therapy (PT) notes within 30 days post-discharge. The total fall count was two, and both patients had been discharged home from Mount Sinai Morningside. Although patients discharged home had higher readmission rates, only a negligible number of these readmissions were related to falls. However, these findings suggest an opportunity to develop a closer follow-up process for patients with higher mobility levels who were transitioned from SAR to home.

Annual Quality and Patient Safety Report

Improving Utilization of a Pneumonia Pathway for Inpatients Care Standardization has been shown to reduce length of stay and readmissions. Led by Dr. Fatma Abdel-Qader, this initiative aims to improve adherence to the pneumonia pathway for inpatients at MSW. Through focused educational interventions and pathway prompts during interdisciplinary rounds, pathway utilization increased from 6.5 percent in 2023 to 38.1 percent in 2025. During the same period, the 30-day mortality rate decreased from 4.8 percent to 0.8 percent. A rise in readmissions to 11.0 percent in 2025 was identified and under review. This work will continue in 2026.

Annual Quality and Patient Safety Report

Central Hospitalist

The central hospitalist (CH) program began as a pilot program in 2022 to improve health care system throughput, quality, and efficiency, with the goal of putting “the right patient, in the right bed, at the right time.” The pilot was successful and in 2025 went through significant structural changes to become a more permanent presence. A core group of nine senior hospitalists were selected in July to work CH shifts as part of their regular employment. In September, the program expanded to seven nocturnists who work CH shifts overnight, thereby providing 24/7 coverage. The primary tasks of the CH are the following: 1. Level loading: Identifying appropriate patients in our most overcrowded emergency department (ED) to transfer to available inpatient beds at other hospitals in the system. 2. Internal transfers: Assisting with moving inpatients from one hospital to another within the system to receive subspecialty care. 3. External transfers: Review requests from external sites to transfer patients into the Mount Sinai Health System hospitals and, when appropriate, facilitate the transfer process. 4. Hospital at Home (HaH) referrals: Screen and refer appropriate inpatients to the Hospital at Home program. 5. Sepsis oversight at Mount Sinai Brooklyn: Ensuring patients meeting sepsis criteria are evaluated for the condition and, if present, receive appropriate and timely interventions. In addition to expanding the number of providers who are CH, the team simultaneously worked on several initiatives to improve operations. For level loading, in addition to ensuring the patient is stable to transfer, it is essential that patients are not moved who need to remain at Mount Sinai Hospital for their care. In coordination with several subspecialty leaders, the guidelines for specific patient populations were expanded. Previous guidelines were developed for HIV/Silver medicine, Oncology, and Sickle Cell. This year, additional guidelines for Renal and Liver transplant and Vascular Surgery were developed. A green/yellow/red paradigm is used for patients who fall into these categories. Kidney transplant criteria is listed below as a reference. Annual Quality and Patient Safety Report

In 2025,1, 1,043 patients boarding in the ED were moved to an inpatient bed at another hospital in the system. This significantly reduces both ED boarding time and overall hospital length of stay (December 2025, see data below).

In 2025, 867 internal and 376 external patients were evaluated for transfer within or into the Mount Sinai Health System and 751 (86%) of internal transfer requests and 191 (50.8%) of external transfer requests were moved (see chart below). When transfer was delayed more than 24 hours, the CH also follows up with the sending sites and re-evaluated the need for transfer. Previously, the CH was not involved after the initial request for transfer. Recognizing that transfer is often delayed days for various reasons and patient condition rapidly changes, it is imperative that the CH monitors the status of initially accepted patients until the transfer process is completed.

Annual Quality and Patient Safety Report

The CH also reviews inpatient cases to send referrals of appropriate patients to Hospital at Home (HaH). Utilizing a software platform developed with Palantir, all inpatients are screened. Manual reviews are then conducted by the CH on patients identified as potential candidates for HaH. Approximately 30-40 percent of HaH admissions are generated through referrals from the CH. During 2025, CH worked with the Palantir team to refine the screening program to better capture patients who are most appropriate for HaH.

CH referral to HaH data for November/December 2025. Red box shows the number of patients marked as “eligible” by the CH and subsequently referred and admitted to HaH. The blue box illustrates the percentage of patients admitted to HaH each period fr om the CH referrals.

In 2026, the CH team will work on standardizing the sign-out process for all transfers (e.g., level loading, internal/external transfers) to ensure patients arrive in stable condition with the appropriate documentation. The CH team is also developing screening tools to preemptively identify the most high-risk transfers and to ensure patients are directed to the appropriate level

Annual Quality and Patient Safety Report

of care. Finally, the CH team also plans to develop practices to better prioritize timing of transfers to optimize time to intervention (e.g., procedure) and overall length of stay.

Hospital at Home

The Mount Sinai Hospital at Home (HaH) program provides inpatient-level medical care to patients in their own homes. The range of services continues to expand and currently includes intravenous treatments (e.g., antibiotics, fluids, diuretics, and other infusions), daily laboratory testing, wound care, supplemental oxygen and oxygen weaning, respiratory treatments, and diagnostic services such as X-rays, ultrasounds, and EKGs. Advanced diagnostics and procedures—including MRI, CT scans, transthoracic echocardiograms (TTE), cardiac catheterization, and biopsies—can also be performed through coordinated round-trip visits to the hospital with specialist teams. The HaH program coordinates care through daily physician video visits, twice-daily in-person nursing visits, video consultations with subspecialists when needed, and 24/7 access to the clinical care team. Ancillary services include physical and occupational therapy, social work, and home health aides. The program also screens for and addresses social needs such as food insecurity, provides internet support when necessary to facilitate care delivery, and offers robust post-discharge services. Patients are eligible for HaH if they require acute hospitalization, reside in New York City (except Staten Island), and have a safe home environment—defined as having running water, electricity, and refrigeration. The program is insurance-agnostic. The referral pathway for HaH is illustrated below. While most patients admitted to HaH have general medical conditions, the program has expanded its clinical capabilities to care for subspecialty populations, including oncology patients and renal and cardiac transplant recipients. In 2025, HaH further expanded to include postoperative care for patients recovering from cardiovascular and ENT surgeries.

Annual Quality and Patient Safety Report

The program strengthened its clinical infrastructure in 2025, expanding consultative services through the Mount Sinai Command Center to include Dermatology, Psychiatry, Wound Care, Hematology, and Palliative Care. It also standardized processes for speech and language evaluations, central line placement, advanced imaging coordination, and wound care assessments. To address social determinants of health, the program implemented a structured food support process for patients with food insecurity and automated social work engagement at discharge to improve connections with community resources.

Hospital at Home Volume and Growth HaH admissions and bed-days saved have continued to grow over the past year. In 2024, the HaH program admitted 821 patients and saved approximately 4,500 direct bed-days for the Health System. In 2025, admissions increased to 1,340 patients, resulting in more than 7,500 bed-days saved. Of all admissions in 2025, 31 percent were admitted directly from the Emergency Department. The graph below illustrates Mount Sinai Hospital at Home admissions and bed-days saved over the past two years.

HaH admits from four MSHS facilities as well as occasionally from patient homes or clinics. The breakdown of bed-days saved by facility is shown in the chart below.

Annual Quality and Patient Safety Report

The Mount Sinai HaH team works closely with the Division of Hospital Medicine to increase referrals and admissions to the program and to improve care transitions between facility-based and home-based settings. At least 50 percent of admissions originated from identifiable referral pathways. Quality and Safety In 2025, HaH cared for more than 1,300 acute patients. Despite this substantial increase in census, care delivered through the program remained safe, high-quality, and patient-centered, as demonstrated in the table below. Escalation rates—defined as patients enrolled in HaH who required transfer back to the hospital for continued care—remained at goal of below 10 percent. Overall, HaH patients experience low care complication rates.

* Hospital Medicine patients from hospitals where HaH admits with LOS <100 days ** HaH LOS includes hospital LOS *** Readmission rates for 1/1/2025-11/30/2025 @ Adverse Events include falls, pressure ulcer injuries, hospital-acquired infections

There was one unanticipated mortality during the year. The patient passed away in the hospital’s Palliative Care Unit on day 11 after being escalated from HaH back to the hospital. This case underwent a comprehensive internal review by the HaH program and the Department of Medicine Quality Improvement Peer Review Committee. In accordance with regulatory requirements, the case was also reported to CMS due to the patient’s Medicare Fee-for-Service status. No concerns were identified.

Annual Quality and Patient Safety Report

The HaH program continues to receive strong endorsement from patients and caregivers. In patient satisfaction surveys, 93 percent of respondents reported that they would recommend HaH to friends and family. Selected qualitative patient feedback is included below. Qualitative Patient or Caregiver Feedback to Hospital at Home

Quality Initiatives HaH remains an evolving care model in which clinical frameworks and operational infrastructure continue to develop. Continuous quality improvement is therefore central to program operations. In 2025, the Mount Sinai HaH program focused on three key areas to strengthen safety and reliability of care delivery: fall prevention, medication safety, and age-friendly care. Fall Prevention Falls remain a major source of morbidity among hospitalized patients, particularly older adults. In 2024, the HaH team implemented a standardized in-home fall risk assessment conducted by registered nurses at the time of admission to home (see diagram below). This structured assessment evaluates both patient-specific factors and environmental hazards within the home. Identified risks are communicated to the interdisciplinary care team—including physical therapy, occupational therapy, and social work—to implement targeted interventions. Fall prevention training was also added to the team’s online education platform and is now part of onboarding for all new nurses.

Annual Quality and Patient Safety Report

In 2025, the program strengthened this work by establishing a Fall Prevention Committee to review cases and standardize best practices. One key recommendation was the implementation of automatic physical therapy evaluations for all patients with at least one fall in the previous six months, regardless of whether a mobility assessment was performed prior to transfer to the home. Evaluating patients in their home environment provides a more accurate assessment of fall risks and functional limitations. Additional prevention measures include providing night lights for patients identified as high risk and supplying mobility aids—such as walkers, rollators, or other durable medical equipment—based on nursing and therapy assessments. Finally, during evening nursing visits, or virtual check-ins when visits occur earlier in the evening, patients are also guided through a “Safe Steps Before Bed” checklist to mitigate common nighttime fall risks.

Annual Quality and Patient Safety Report

Medication Safety Delivering hospital-level care in the home introduces new complexities in medication administration and documentation. Unlike inpatient units where medication delivery occurs within a highly controlled environment, home-based care requires adaptation of these processes while maintaining safety standards. To improve medication administration accuracy and documentation fidelity, the HaH program implemented Epic Rover barcode medication scanning technology in June 2026. This mobile-based system mirrors hospital barcode medication administration workflows and allows nurses to scan medications at the point of care during home visits. Following implementation, medication scanning adherence improved steadily, reaching the program’s target rate of 85 percent adherence for all scannable medications (see chart below).

Annual Quality and Patient Safety Report

Some medications cannot be scanned when they are administered in a home environment. These include therapies delivered through alternative systems such as elastomeric infusion pumps, non-formulary medications, or medications taken by patients independently outside of scheduled nursing visits. Despite these inherent limitations, the implementation of Rover represents an important step toward aligning home-based medication administration with hospital-level safety practices. Age-Friendly Care In 2025, the Centers for Medicare & Medicaid Services (CMS) introduced a new inpatient quality measure evaluating Age-Friendly Health Systems principles through the 4Ms Framework: What Matters, Medications, Mentation, and Mobility. To assess how Hospital at Home aligns with this framework, the Mount Sinai HaH program conducted a retrospective chart review of 140 patients aged 65 years and older who were admitted to the HaH program between January and August 2025 from the Emergency Department. Clinical documentation was reviewed for elements aligned with the CMS 4Ms framework, including what matters, medications, mentation, and mobility. The review demonstrated that the HaH patient population reflects the diverse and medically complex urban population served by Mount Sinai, supporting the feasibility of delivering age-friendly care across varied patient populations. The program consistently incorporates multiple components of the CMS 4Ms framework. (See tables below.) DEMOGRAPHICS (n=140)

Annual Quality and Patient Safety Report

Age-Friendly Care Domain Results

The analysis identified opportunities for improvement. Despite an older patient population, documented goals-of-care discussions were relatively low (9 percent), with opportunities to increase identification of health care proxies or surrogate decision-makers. In addition, the review identified unintended medication discrepancies between admission documentation and medications patients were taking at home, highlighting the importance of medication reconciliation. Addressing these gaps will be a focus of future quality improvement efforts within the HaH program. Mount Sinai Hospital at Home remained a national leader in scholarship and innovation in 2025, producing 16 scientific abstracts—including one national award winner and one finalist— publishing three peer reviewed manuscripts, and delivering five invited national presentations. The program launched an acute-care Hospital at Home rotation for trainees across the Health System, exposing them to all aspects of the model; 41 trainees have completed it, supported by a lecture series and web based platform. Anonymous feedback shows the elective increased familiarity with the model, confidence in core home-based acute-care skills, and interest in future involvement. Program leaders also contributed to national collaboratives, professional societies, and policy initiatives advancing Hospital at Home programs.

Quality Improvement Peer Reviews (QIPR) The DOM Quality Improvement Peer Review Committee at each site reviews all mortality and morbidity cases and convenes monthly to identify potential quality concerns. Prior to each meeting, cases are reviewed by faculty members or by house staff under faculty supervision. Cases that raise quality concerns are escalated for comprehensive committee review. Additional cases are referred by faculty, SafetyNet, or through the hospital’s serious adverse event (SAE) process, and even when hospital-level review concludes that the standard of care (SOC) was met, the departmental review often identifies opportunities for improvement within the department. This interdisciplinary committee—comprising a broad range of health care professionals— discusses each case and votes on whether the SOC was met. If the SOC is determined not to have been met, or to have been met with opportunities for improvement, the committee identifies areas for improvement, discusses strategies to enhance patient safety, and implements a safety solution plan to reduce the risk of recurrence. When provider errors are identified, the involved providers receive counseling. The sections below summarize the findings of the QIPR committees and outline the quality initiatives that were developed to address identified opportunities for improvement.

Annual Quality and Patient Safety Report

In 2025, the Division reviewed 142 mortality cases compared to 143 cases reviewed in 2024. Sixty-nine patients had a Do Not Resuscitate (DNR) status after admission, compared to 38 that had DNR status prior to admission (see graph below). The patients would have benefitted from Palliative Care consultation during the admission in 18 mortality cases in the past year, an increase from the previous year of 11 cases. Early involvement of palliative care will be a priority in 2026.

Of the 142 cases reviewed in 2025, 120 (84 percent) met the standard of care (SOC). In 2025, seventeen cases (12 percent) met the SOC with an opportunity for improvement. There were four patient cases that did not meet SOC. The SOC is not scored for patients who die in hospice care, only one patient met this criterion in 2025.

Annual Quality and Patient Safety Report

The most common factors attributed to mortalities and adverse events were treatment delays (n=10), delay in diagnosis (n=7), delay in addressing an abnormal test (n=7).

In 2025, mortality trends among racial and ethnic groups remained relatively stable from 2024, generally aligning with years prior and with discharges as depicted in the three graphs below. The QIPR committee will continue to monitor this data in 2026 to identify any variances, should they develop.

Annual Quality and Patient Safety Report

Percent of Deceased Patients by Race/Ethnicity: Hospital Medicine Service (2022-2024) 34.4% 25.9%

27.8%

25.9%

24.7%

27.3%

25.2% 23.4% 20.5%

11.4%

7.9% 4.6%

Black or African American

White

Hispanic

2022 (n=158)

8.2% 7.3%

Other

2023 (n=151)

7.2%

Asian

6.3%

5.3% 5.8%

Unknown

2024 (n=139)

Percent of Discharges by Race/Ethnicity: Hospital Medicine Service (2022-2024) 30.6% 29.5%

29.4% 28.8%

28.8%

30.5%

24.6% 25.3% 23.9%

2022 (n=8064)

8.2% 8.7% 7.6%

2023 (n=8243)

2024 (n=9372)

5.3% 5.8% 6.0% 1.7% 1.7%

Black or African American

White

Hispanic

Annual Quality and Patient Safety Report

Other

Asian

2.8%

Unknown

In 2025, a range of patient safety initiatives were implemented to enhance both clinical care and workflow processes. The committee’s efforts in 2025 have involved education, culture change, and collaboration with other departments. There were 17 cases identified with room for clinical improvement. As part of the safety solution, several cases were presented at the Resident Quality Improvement conference as well as the Division of Hospital Medicine (DHM) QIPRC meeting for further discussion and education. Some of the topics presented include buprenorphine and management of patients with addiction and withdrawal, opportunities for escalation to the psychiatry crisis line and education on how to utilize it and learning from individual cases. Changing culture can be a challenging task. One case highlighted a practice of Medicine and Medicine subspecialty teams delaying consultation of Oncology without a biopsy confirmed diagnosis of cancer, even when the suspicion for malignancy was high. Through this case, education was provided to Hospital Medicine, Infectious Disease, and Critical Care that earlier formal consultation with Oncology for patients with suspicion of malignancy can help expedite the oncologic work-up and care, especially for hematologic malignancies such as lymphoma. Lessons learned from this case were distributed throughout the Mount Sinai Health System. The committee worked with several groups to enhance workflow issues that were identified in case reviews. For instance, the committee worked with the Medicine Residency Program and the Night Hospitalist group to improve overnight resident escalations to nocturnists for clinically significant events. The committee collaborated with several other clinical service groups to address vulnerabilities identified in case reviews, including Hospital at Home, the Pulmonary Embolism Response Team (PERT), Nursing, and the Emergency Department. Several cases resulted in the creation of longitudinal QI projects. One case, for instance, identified delay in discussion of goals of care and spurred the creation of a project to automate Palliative Care consultation for sick patients who meet a variety of clinical conditions. Through this project, entitled Advance Care Planning Automated Consult Trigger, the Medicine Palliative care team has so far reached out to teams to initiate advanced care planning conversations in 10 patients. This project will continue in 2026.

Annual Quality and Patient Safety Report

A total of 90 hospital medicine mortalities were reviewed. Twenty-four cases required further review. Sixty-three out of 90 patients had palliative care involvement during their hospital course. There were eight cases where the reviewer thought palliative care should have been consulted when it was not.

Annual Quality and Patient Safety Report

Thirty-five percent of patients identified as Black or African American, 32 percent identified as other, and 28 percent identified as White.

The most common primary language was English at 56 percent, followed by Spanish at 20 percent. The information was not collected in 22 percent of patients.

Annual Quality and Patient Safety Report

Sixty-three percent of patients identified as non-Hispanic, 34 percent as Hispanic, and 2 percent as unknown.

The standard of care was deemed met in 58 cases, met with room for improvement in 15 cases, and not met in 9 cases.

Annual Quality and Patient Safety Report

The most common contributing factors, as above, were delay in treatment, delay in addressing abnormal test results, and inappropriate medication utilization.

Areas Identified as Opportunities for Improvement Delays in escalation of care to the attending or critical care service were identified in three of the peer-learning sessions in 2025, prompting further investigation into the current escalation culture and behavior of the internal medicine residents at MSMW. A baseline survey was sent to 140 PGY-2 and 3 residents, with a response rate of approximately 50 percent. Responses noted as below. Only 20 percent felt very comfortable escalating acute clinical status changes, about three-quarters reported that they rarely or never contacted an attending in the evening hours, and only 20 percent felt very comfortable reaching out to the nocturnists.

Annual Quality and Patient Safety Report

Rapid responses and safety nets were reviewed to determine whether delayed escalation to supervising attendings impacted patient safety. Targeted review of internal medicine rapid responses (RRTs) in April and July-September of 2025 found that at least five cases a month had delays in escalation. Sample delays in escalation: •

Young woman with PMHx psychiatric disorder admitted overnight with abdominal pain. Found to have LFTs in the 1000s, acute renal failure, later discovered to have ingested large quantities of Tylenol. Neither ICU nor GI consulted by night team, not discussed with nocturnist. Day team called GI and ICU screen, required admission to the ICU given concern for acute liver failure.

•

Older gentleman admitted and treated for C. diff who overnight developed acute hypoxic respiratory failure (room air → NC → NRB → HFNC). The day team found the patient on BIPAP with subsequent RRT for AMS and worsening respiratory status.

To decrease the number of RRTs attributed to delays in escalation of concerns to attendings among the MSMW internal medicine residents, the Division has implemented several interventions: 1) a presentation to the hospitalists during a noon conference regarding the overall goals of the project, 2) implementation of an evening check-in between the day hospitalist and the resident between 6-8 pm, and 3) a nocturnist check-in with the senior residents at the beginning of the night shift. The absolute number of RRTs/month related to delays in escalation of care did decrease after the interventions. When evaluating as a percentage, the RRTs/month attributed to delays in escalation of care appeared higher in more recent months. However, a recent labor disruption at our institution brought the overall census/number of RRTs/month much lower than our normal average. (see graphs below). Preliminary survey data of 29 residents out of 70 showed that 27 found the evening check-in helpful. On average, most residents received a check-in between five to seven times a week.In 2026, the Division plans to address delays in palliative care consultations and to explore if language barriers are playing a role in end-of-life conversations.

Annual Quality and Patient Safety Report

In 2025, 118 mortality cases were reviewed by faculty. Most patients (78%, n=92) had palliative care involvement, and 61 percent (n=72) were under comfort care. Seven were receiving hospice services at the time of death. Thirty-three percent (n=39) of patients had a Do Not Resuscitate (DNR) order prior to admission, with an additional 47 percent (n=55) transitioned to DNR status during hospitalization. Thirty-nine percent (n=46) spent time in the ICU during hospitalization. Four percent (n=5) died within 24 hours of being admitted. A total of 16 cases were identified for further review.

Annual Quality and Patient Safety Report

Most patients were English-speaking (73%, n=80). Other primary languages included Spanish (7%, n=8), Cantonese (4%, n=4), Albanian (1%, n=1), Estonian (1%, n=1), Italian (1%, n=1), and Korean (1%, n=1). Language data were not collected for 12 percent of patients (n=13).

Regarding race, 50 percent of patients (n=54) were White, 21 percent (n=23) were Black or African American, and 19 percent (n=21) identified as other. Six percent (n=6) were Asian. Race was unknown for 4 percent of patients (n=4), and 1 percent (n=1) declined to disclose their race.

Annual Quality and Patient Safety Report

Ethnicity of patients was as follows: 79 percent (n=86) were non-Hispanic, and 16% (n=17) were Hispanic. Ethnicity was unknown for 6 percent of patients (n=6).

Following case review, faculty determine whether the standard of care (SOC) was met, met with opportunity for improvement (OFI), or not met. Cases that do not meet the standard of care, or that present an opportunity for improvement, are reviewed, and those deemed appropriate are selected for discussion at monthly QIPR meetings.

As shown in the graph above, the majority of mortality cases continued to meet the standard of care in 2025, with 80 percent of cases (n=94) meeting SOC, compared with 85 percent (n=127) in 2024. Cases categorized as SOC met with opportunity for improvement accounted for 8 percent (n=10) in 2025 and 6 percent (n=9) in 2024. Cases not meeting the SOC were 5

Annual Quality and Patient Safety Report

percent (n=6) in 2025 and 9 percent (n=13) in 2024. A small proportion of cases were not scored because patients were under hospice care on admission (7%, n=8 in 2025; 5%, n=5 in 2024) and therefore did not require further review. Contributing factors in cases that did not meet the standard of care included treatment delays (n=3), hospital falls (n=2), goals of care not documented (n=2), failure to escalate (n=1), a hospital-acquired condition (n=1), poor documentation (n=1), and inappropriate treatment provided (n=1).

Following the identification of cases where the standard of care was not met, key areas for improvement were identified and addressed through corrective actions. Morphine Use in Patients with Impaired Renal Function Two cases with adverse outcomes associated with morphine use in patients with impaired renal function highlighted the need for safeguards around morphine prescribing in patients with acute kidney injury or advanced chronic kidney disease, including those on dialysis. Following discussion of these cases at the systemwide pain committee, a collaborative effort between hospital medicine, pharmacy, and IT led to the development of a Best Practice Advisory (BPA) to discourage morphine use in patients with an eGFR < 30 mL/min. A retrospective review of morphine orders placed in adult inpatients with an eGFR <30 mL/min from January 2024 to October 2024 across the Health System revealed an average of 172 highrisk orders per month (184 orders per month per 10,000 discharges when adjusted for discharge volume). The morphine BPA was a passive alert and triggered whenever morphine was ordered for patients with an eGFR < 30 mL/min, reminding prescribers of renal impairment and suggesting alternative opioids with lower renal clearance, such as hydromorphone or fentanyl (Figure 1). From implementation in November 2024 through August 2025, the BPA reduced inappropriate orders to an average of 102 per month (109 per month when dischargeadjusted), representing a 41 percent decrease (Figure 3).

Annual Quality and Patient Safety Report

Figure 1. Passive Best Practice Advisory Alert

Although effective, the BPA’s full impact was limited by frequent bypasses, prompting a revision of the alert from a passive to an actionable form, with a soft stop requiring prescribers to either cancel the order or to acknowledge it and provide a justification for proceeding. Acknowledgment options included: 1) single dose with close monitoring, 2) intolerance or failure of alternatives, 3) patient on comfort care, and 4) “other,” with a mandatory free-text explanation (Figure 2). Since the implementation of the actionable BPA in September 2025, inappropriate morphine orders have decreased to an average of 59 orders per month (60 when dischargedadjusted), representing an additional 42 percent reduction and a total decrease of 66 percent from baseline (Figure 3).

Figure 2. Actionable Best Practice Advisory Alert

Preliminary analysis of November 2025 revealed that 48 percent of triggered BPAs were bypassed, with 75 percent citing “single dose with close monitoring,” 4 percent “intolerance or failure of alternatives,” 11 percent “comfort care,” and 10 percent “other” as reasons for override. Reasons for bypassed BPAs will be reviewed to assess trends, with the intent of providing feedback to ordering providers as appropriate.

Annual Quality and Patient Safety Report

Morphine Prescribing in Patients with eGFR < 30

150

BPA

Actionable

200

BPA

Passive

Number of Orders

250

100 50

Nov-25

Oct-25

Sep-25

Aug-25

Jul-25

Jun-25

May-25

Apr-25

Mar-25

Feb-25

Jan-25

Dec-24

Nov-24

Oct-24

Sep-24

Aug-24

Jul-24

Jun-24

May-24

Apr-24

Mar-24

Feb-24

Jan-24

Time Number of new orders

Number of new orders per 10,000 discharges per month

Figure 3. Morphine prescribing trend from January 2024 to November 2025.

Capacity Assessment and Documentation in AMA Discharges Two cases of patients who left against medical advice (AMA) but were deemed to lack capacity by psychiatry when readmitted with a worsening clinical status prompted a review of the approach to capacity assessments in AMA discharges. One hundred charts of patients on the general medicine service at MSW with AMA discharge orders from July 2024 through June 2025 were reviewed. Eight charts were excluded: four elopements, two patients who left AMA from the ED before admission, one inter-hospital transfer, and one routine discharge, leaving 92 charts for final analysis. Documentation of capacity was reviewed for the four widely recognized Applebaum criteria, which include: 1) ability to communicate a clear and consistent choice, 2) understanding the relevant information, 3) appreciating the medical consequences of the situation, and 4) reasoning about treatment choices. Documentation of all four Applebaum criteria was completed in only 8 percent of charts reviewed. Three criteria were documented in 21 percent of charts, two in 46 percent, one in 16 percent, and none in 10 percent (see chart below). Expression of choice and appreciation of risks were most frequently documented (85% and 64%, respectively), whereas reasoning in support of the decision to leave AMA and understanding of the medical condition were less consistently recorded (39% and 12%, respectively) (see chart below).

Annual Quality and Patient Safety Report

Number of Capacity Elements Documented

Types of Capacity Elements Documented

46%

21%

16% 10%

Percentage of Charts

85%

64%

39%

12%

Communicate Choice

Number of Capacity Elements

Understand Condition

Appreciate Risks

Reasoning

Capacity Element

To gain insight into provider attitudes towards capacity evaluations, the team surveyed internal medicine residents, advanced practice providers (APPs), and attendings to assess their comfort with performing and documenting capacity assessments, perceived sufficiency of training, and interest in an EMR-based support tool to guide capacity documentation. Responses were reported on a 5-point Likert scale (1=low, 5=high). Survey responses were received from 70 of 230 residents (30%), 14 of 22 APPs (64%), and 20 of 36 attendings (56%), for a total of 104 clinicians. Residents and APPs reported moderate confidence in bedside assessments (residents 3.4, APPs 3.0) and documentation (residents 3.0, APPs 3.3), whereas attendings reported higher confidence in both domains (4.3 and 4.0, respectively). Perceived sufficiency of training was low among residents and APPs (2.5 each) but higher for attendings (3.4). Interest in an EMR-based template to guide capacity evaluations was high across all groups (residents 4.5, APPs 4.8, attendings 4.5) (see chart below). Provider Insights on Capacity Evaluation and Documentation 3.4

Confidence in bedside assessment

Confidence in documentation

3.3

3.4 4.5

Interest in EMR-based template

Annual Quality and Patient Safety Report

2.5 2.5

Sufficiency of training

Residents

4.3

4.8

4.5

APPs

Attendings

In collaboration with psychiatry, case-based educational sessions on capacity evaluation were conducted for house staff and APPs in November and December 2025. Educational materials were created and disseminated in resident and APP workrooms. Ongoing chart reviews are in progress, and preliminary work has begun on the development of an EMR documentation template. Identification of DNR Patients with Wristbands Inappropriate initiation of a medical code on a patient with a DNR code status prompted a review of the DNR identification policy. A single walk-through of non-ICU floors revealed that 53 percent (10 of 19) of patients with a DNR code status lacked a DNR wristband. Further discussions will be held with nursing leadership to examine and modify current protocols to streamline appropriate wristband placement in 2026. Temporary Hemodialysis Catheter Policy Change A case of a patient with excessive bleeding requiring ICU transfer for vasopressor support after removal of a temporary non-tunneled hemodialysis catheter by the medicine team prompted a policy change to shift the removal of such catheters from medicine to the vascular service. Additionally, the policy was revised to mandate removal of temporary hemodialysis catheters at the time of conversion to a tunneled catheter, without waiting for confirmation of tunneled catheter function. This change will reduce procedural complications and shorten temporary catheter dwell times. Policy compliance, catheter dwell time, and complications will be tracked into 2026.

The peer review committee reviewed 71 cases of patients who expired in 2025. This represents a decrease from 113 cases in 2024. One case was flagged for further review, and five cases met the standard of care but required improvement. Palliative care was involved in 55 cases, while two cases were flagged for missed palliative care consultation. Fifty patients had an ICU

Annual Quality and Patient Safety Report

stay. Fifty-eight patients had a DNR order at some point during their admission. Thirty-one patients were transitioned to comfort care but were not enrolled in hospice.

Cases with opportunities for clinical improvement were presented at monthly Medicine conferences as provider education. Targeted education was also provided to specific providers involved in the case when warranted.

In 2025, all rapid response events were reviewed and pneumonia readmission cases from 2024 prompted an evaluation of aspiration prevention practices among nursing staff and medical providers. Forty-eight percent of cardiac arrests were potentially attributable to aspiration. An Aspiration Prevention Workgroup was established at Mount Sinai Queens in 2025. The team

Annual Quality and Patient Safety Report

advocated appropriate ordering of aspiration precautions when indicated, as well as consistent nursing implementation of aspiration precaution orders, including maintaining the head of bed at 30 degrees and ensuring suction equipment availability. The work group also developed a nursing policy on aspiration prevention that was accepted throughout the Health System. In 2026, Epic changes will be made to help identify high-risk aspiration patients, which will also impact the Health System. Additionally, a case involving D-dimer testing for an elderly patient identified a gap in medical knowledge around age-adjusted D-dimer testing in low- to intermediate-risk patients. Further testing could have been avoided in this case had the age-adjusted D-dimer testing been utilized and the care focused on other etiologies likely responsible for the patient’s hypoxia. Education on age-adjusted D-dimer utilization and Well’s score for determining risks was provided at a hospital medicine team conference. The use of these tools is being monitored and will continue in 2026.

Infectious Diseases

The Division of Infectious Diseases plays a critical role in delivering high-quality care while advancing education and prevention. This section summarizes key quality initiatives and outcomes that demonstrate the Division’s impact over the past year throughout the inpatient hospitals as well as at the Mount Sinai Health System’s Institute of Advanced Medicine (IAM), composed of the Samuels Clinic, the Peter Kruger Clinic (PKC), and the Jack Martin Fund Center (JMFC) at Mount Sinai-Harlem Health Center. HIV Viral Suppression Initiatives At IAM, the Jack Martin Fund Clinic relocated to the Harlem Health Center in late 2023, where the program consolidated with Mount Sinai Morningside, to continue to provide HIV ambulatory services. Through this expansion and expanded outreach, patient volume grew by

Annual Quality and Patient Safety Report

approximately 3,700 individuals. Suppression rates remain strong, with 91 percent of JMFC patients (steady from 91 percent in October 2024), and 93 percent across IAM, including the Samuels Clinic, achieving virologic suppression as of October 2025. These outcomes are supported by the Department of Health-funded care coordination program and the innovative long-acting injectable (LAI) antiretroviral therapy initiative. The LAI program has successfully transitioned 20 previously unsuppressed patients to suppression (<100 copies/mL), demonstrating the effectiveness of multidisciplinary collaboration and targeted interventions. A dedicated quality improvement group ensures the timely receipt of medication, HIV viral load monitoring, and health maintenance such as STI screening. This work will continue in 2026. At PKC, the Division implemented a comprehensive approach to address barriers such as mental health, substance use, and housing instability in addition to care coordination and medication adherence. Using standardized treatment failure guidelines and intensive monthly follow-up, the clinic achieved 52 percent suppression by Q3 2025 among a cohort of 71 previously unsuppressed patients identified at the end of 2024, surpassing its goal of reducing unsuppressed patients by 50 percent. Weekly reports guided outreach efforts, thereby ensuring follow-up appointments, medication adherence, and patient education. Standardized guidelines and a treatment failure checklist were implemented, including resistance testing, social service referrals, monthly follow-ups, and multidisciplinary reviews. Nurses, social workers, and care coordinators addressed barriers such as mental health, substance use, housing instability, and insurance challenges. Onsite psychiatry and psychotherapy enhanced linkage to mental health care, contributing to improved engagement. With these efforts, the Division will continue to work towards the goal of 50 percent of patients with virologic suppression in 2026 at PKC. These initiatives reflect a systemwide commitment to evidence-based strategies and multidisciplinary teamwork to improve HIV outcomes and reduce disparities. Health Maintenance for Patients with HIV Vaccination The Division has devoted significant efforts toward COVID-19 vaccination since the vaccines became widely available and has monitored vaccination metrics closely since April 2021. In 2025, the Division expanded its focus to include influenza and RSV vaccination. To streamline the process of tracking vaccination rates, a vaccination dashboard was spearheaded at JMF/HHC, which was built to monitor vaccination rates for influenza, RSV, and COVID vaccination among all IAM patients. The dashboard can be filtered by clinic site within IAM, provider, and patient age. Considering increasing barriers to vaccination, including confusing messaging and variable access, the Division will enhance efforts to improve vaccination rates using the dashboard. Planned efforts for the winter respiratory viral season include targeted education to providers and MyChart blast messaging to patients. In addition, patient-directed education regarding RSV

Annual Quality and Patient Safety Report

vaccination specifically was designed as part of a recent fellow quality initiative and is being disseminated to IAM clinics. Last year, by the end of the spring season, 23 percent of patients at JMF/HHC had received COVID vaccination. This year, the goal will be to vaccinate 30 percent of patients. As of early November, 22.1 percent of patients at JMF/HHC had received influenza vaccination; the goal will be to reach 40 percent. Finally, RSV is currently recommended as a single dose, rather than seasonal vaccine, and as of early November 2025, approximately 15 percent of patients at JMF/HHC who are eligible had been vaccinated. The Division is aiming to increase this rate to 20 percent by the end of the RSV season in spring 2026. Cervical Cancer Screening In August 2023, PKC’s onsite GYN services concluded, leaving only two part-time providers to manage patients. This change delayed improvement efforts to increase cervical cancer screening rates at this IAM site. Additional challenges and limitations include patient nonadherence to screening appointments despite reminder phone calls, patient discomfort with screening by a male provider, some insurances not covering the service, and overstretched referrals to a female gynecology provider. By October 2024, the YTD average cervical cancer screening completion rate dropped to 37 percent. In 2025, the team continued its focus on improving cervical cancer screenings by continuing to follow their workflows, identifying those who are due for cervical cancer screening, providing counseling and education by nursing staff, and appointment reminders by care coordination. By mid-2025, the team will welcome an additional part-time provider to manage patients. As of Q3 2025, there were 114 patients eligible for screening, with 63 completing screening, leading to a screening rate of 55.3 percent (from 37 percent in the prior year). The goal is to reach 75.4 percent. The team will continue the efforts through the improved workflows and processes. Antimicrobial and Diagnostic Stewardship Firstline App The ID Division began to focus on developing an app to support antimicrobial stewardship efforts in 2023, through a collaboration with Firstline and the NYC Department of Health and Mental Hygiene (DOHMH). The app went live in January 2024 and since then, the Division has devoted significant efforts to optimizing it and promoting usage. In 2025, the Firstline app was further expanded to Mount Sinai South Nassau and is now in use across the Mount Sinai Health System. The antimicrobial stewardship (AS) team continues to educate providers with an annual push to new house staff during orientation in June and July, ongoing reminders to front-line providers during the antibiotic approval process, email blasts, and targeted training. There have been more than 73,000 sessions since the app launched, with 150-250 users per day (see below figure) and 1,100-2,600 users per month. Usage remains highest at MSH and is growing at other sites in the system. The AS team collaborated with Allergy/Immunology in 2025 to update the guidance on penicillin allergy management, with a focus on systemwide perioperative prophylaxis guidelines. The AS team also worked on a collaborative project led by hospitalists and

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medical students, which leveraged Firstline guidance to increase IV to PO antibiotic transitions for hospitalized patients with community-acquired pneumonia or urinary tract infections. Finally, the app has been utilized throughout the year for messaging urgent notifications regarding antimicrobial shortages. Updates and new content are planned for 2026, including updates to institutional transmissionbased precautions and the addition of guidance on HIV PEP and PrEP, latent tuberculosis screening and treatment, and management of intra-abdominal infections. As the urinary tract infection algorithm remains the most frequently viewed guideline, the AS team plans to perform a review in 2026 to assess the impact of Firstline on UTI management and alignment with institutional guidance.

De-Escalating Anti-Pseudomonal Antibiotics in Patients with Pneumonia Based on Respiratory Cultures in Critical Care Units at MSMW Sputum cultures are recommended by IDSA/ATS for all inpatients treated empirically for methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa (PSA) pneumonia and in patients with severe disease. De-escalation of broad-spectrum antibiotics to standard community-acquired pneumonia therapy is recommended if cultures do not reveal a drug-resistant pathogen and the patient is clinically improving. PSA is the most common cause of nosocomial infections and has a high rate of carbapenem resistance. To evaluate adherence to recommendations, cases were reviewed involving patients with a pneumonia diagnosis who were started empirically on antipseudomonal antibiotics and admitted to critical care units at MSMW between January 2024 and March 2024. Targeted therapy (TT) was defined as (1) the tailoring of antibiotics to the specific pathogen(s) identified in the index culture, by changing to a narrower spectrum antibiotic dictated by culture and sensitivity data, or (2) stopping antibiotics altogether if cultures are negative. Conversely, not targeted therapy (NoTT) was defined as (1) enrollment culture was negative and antibiotics were continued, (2) enrollment culture was positive and broad-spectrum antibiotic therapy was continued when a narrow-spectrum antibiotic would have been sufficient, or (3) enrollment culture was positive and gram-positive organism(s) alone were isolated, but gram-negative coverage was continued. The Sequential Organ Failure Assessment (SOFA) scores at the time of their ICU admission were calculated to ensure that the two groups had similar risk for ICU mortality. To standardize the sputum collection process and improve accountability for collection, respiratory cultures Annual Quality and Patient Safety Report

were collected by a respiratory therapist. Daily huddles included reminders to house staff and nursing staff about the importance of collecting respiratory cultures on all patients admitted with pneumonia. An educational session to critical care faculty and fellows was also conducted on the impact of targeted therapy in patients admitted to the ICU with pneumonia on mortality, ventilator-free days, as well as other clinical outcomes. A total of 82 patients were included in the baseline; 57.3 percent were on TT and 42.7 percent were on NoTT. 21.3 percent of patients on TT grew PSA in respiratory cultures; and out of these patients, 80 percent had one or more risk factors for PSA infection as defined in the 2019 IDSA/ATS guidelines (see table below). Baseline data showed that patients admitted to the ICU with a pneumonia diagnosis who are treated with targeted therapy have a lower ICU mortality as compared to patients who remain on broad spectrum antibiotics. The goal of this project is to improve the rate of respiratory culture collection and deescalation of antibiotics based on culture data via several initiatives, including the ongoing house staff and nursing staff education and the assigning of responsibility of respiratory culture collection to respiratory therapists. This project will continue in 2026.

Optimized Urine Culture Protocol (OUCP): Transforming and Optimizing Urine Culture Utilization in Emergency Medicine at MSMW and MSH Urinalysis (UA) and urine cultures (UCs) are commonly used diagnostic tools in the emergency department (ED). Both tests are frequently ordered simultaneously without review of the UA, contributing to unnecessary urine cultures, treatment of asymptomatic bacteriuria, and avoidable health care costs. To address this, a process change was implemented in the EDs at MSMW and MSH in which a UC was performed only if the UA suggested a urinary tract infection, defined by the presence of pyuria (white blood cells >10 per high-power field). UAs automatically reflexed to UCs only when pyuria criteria were met in the updated laboratory workflow. Pre-intervention data from September through November 2023 were compared to data from the same three-month period following implementation. Medical records were reviewed to assess UA results, reflexed urine cultures, microbiologic findings, and subsequent antibiotic use. Urine cultures were categorized as likely positive or likely negative based on institutional standards for colony-forming units and organisms identified.

Annual Quality and Patient Safety Report

During the pre-intervention period, 3,869 UAs were obtained, and 1,556 (40.5 percent) urine cultures were processed. Following implementation, 4,436 UAs were performed, of which 1,069 (24.1 percent) reflexed to urine culture. Post-intervention, 3,367 UAs (75.9 percent) did not meet pyuria criteria and therefore did not trigger culture processing. This represented a 32 percent absolute reduction in urine cultures processed, with reflex rates decreasing from 40.5 percent to 24.1 percent (χ² = 48.7, p < 0.05). In addition, the proportion of likely positive urine cultures increased from 21 percent pre-intervention (329 cultures) to 35.7 percent post-intervention (382 cultures) (χ² = 69.4, p < 0.05). Based on institutional cost data, annualizing these reductions resulted in an estimated cost savings of $178,920 to the Health System. The UA-to-UC reflex process resulted in improved diagnostic yield, reduced processing of clinically insignificant cultures, decreased unnecessary antibiotic exposure for asymptomatic bacteriuria, and substantial cost savings. In addition to the efforts related to the Firstline app, sputum cultures, and urinalysis with reflex, there are several active QI projects developed by current or recent Infectious Diseases fellows related to antimicrobial and diagnostic stewardship. The Division developed a systemwide committee of ID faculty to focus on diagnostic stewardship efforts that can provide oversight and systemwide input on these initiatives. A recently graduated ID fellow initiated a project during their fellowship to optimize the use of serum (1-3)-beta-D-glucan testing. This project has continued and is being led by two current internal medicine residents. The diagnostic stewardship committee recently reviewed and approved guidance on serum (1-3)-beta-D-glucan testing that can now be built into a revised order in the electronic medical record. A current second-year ID fellow is working on the development of clinical guidance on the use of nextgeneration sequencing (NGS) tests for Infectious Diseases. This guidance has also been approved by the diagnostic stewardship committee. Finally, another current second-year ID fellow is working on a project, in collaboration with Ethics and Palliative Care, to optimize the use of antimicrobials in patients at the end of life. A needs assessment has been distributed to faculty and trainees and will be used to guide interventions for this project. Additional Projects •

One current second-year ID fellow is working on a quality initiative to improve the rate of high-dose influenza vaccination in transplant recipients (Second-Year MSH Fellow Project).

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Another current second-year ID fellow is working on a medical education-oriented QI project to enhance the HIV medicine curriculum on the inpatient Silver (HIV Medicine) rotation, and improve the HIV/ID knowledge among internal medicine house staff at MSH (Second-Year MSH Fellow Project).

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At PKC, the ID team sought to increase Health Care Proxy Completions for established patients with HIV 65 years and older. In 2024, there were 283 patients who met the age criteria; 170 (60 percent) patients had health care proxies completed. By Q3 2025, 61 percent of patients had health care proxies completed. This work will continue in 2026 (MSMW).

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Oral care policies across the MSHS system were reviewed and standardized by an ID fellow at MSMW to create a systemwide oral care policy that was incorporated into the daily care flow sheet for nursing documentation. In addition, a computer-assisted algorithm to identify cases of hospital-acquired pneumonia in nonventilated patients was developed. This project will continue in 2026 and will monitor compliance with the updated policy and the number of cases of hospital-acquired pneumonia.

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Liver Medicine

In response to the high prevalence of chronic hepatitis C virus (HCV), hepatitis B virus (HBV), and hepatitis delta virus (HDV) infections in New York City (NYC), Mount Sinai’s Division of Liver Diseases aims to enhance screening rates and subsequent linkage to care and treatment for patients who test positive for these viral diseases across the Mount Sinai Health System (MSHS). Hepatitis C The New York City Department of Health and Mental Hygiene (NYCDOHMH) estimates that approximately 0.7 percent of New York City residents have chronic HCV, with newly reported cases down to 2,375 in 2023, compared to 7,216 in 20141. While the city and the MSHS have made tremendous strides in identifying and treating patients with HCV, disparities persist, with younger people less likely to be cured. In the MSHS, the Division found disparities in linkage to care by insurance type. In 2024, New York State mandated universal HCV screening for adults and linkage to care for anyone testing positive. Mount Sinai’s Division of Liver Diseases had already implemented the infrastructure to encourage universal HCV screening prior to this mandate, including a health maintenance topic and BPA for primary care providers in the Epic electronic medical record (EMR). The Division’s LEAP patient navigation program also continued offering patient navigation and comprehensive care coordination for HCV-positive patients. In 2025, 129,522 unique patients were screened for hepatitis C, compared to 134,700 unique patients screened in 2024 (Figure 1). 411 patients (0.3%) were found to have HCV RNApositive results, slightly decreased from 507 (0.4%) in 2024. An additional 663 patients identified

New York City Department of Health and Mental Hygiene. Hepatitis A, B, and C in New York City: 2023 Annual Report. Long Island City, NY. 2024

Annual Quality and Patient Safety Report

prior to 2025 with a positive HCV RNA test were found to still be HCV RNA-positive. Therefore in 2025, there was a total of 1,074 patients identified with HCV RNA-positive results. 467 or 43 percent of these patients were already on guideline-recommended HCV treatment. 607 or 57 percent were not engaged in HCV treatment, of whom 274 or 45 percent were eligible for outreach from the Division’s LEAP team. 252 patients or 92 percent received at least one outreach attempt via phone or MyChart message, and 132 patients or 52 percent attended at least one appointment with an HCV provider. The LEAP team’s patient navigators utilize a weekly Epic report to identify HCV-positive patients, conduct chart reviews, and provide outreach to patients requiring HCV care. Navigators employ a comprehensive approach, making multiple phone attempts, sending physical letters or MyChart messages, and reopening cases when patients re-engage anywhere in the MSHS. Once a patient is engaged, the navigators provide health education, schedule HCV evaluation appointments, offer reminders, assist with insurance, transportation, and referrals to primary care and services. The Division also collaborates with the ED’s health education program to engage HCV-positive patients seen in the ED.

Figure 1. HCV Screening and Care Pathway across the MSHS system in 2025. MSSN was added after their Epic “Go-Live” in late 2025.

Hepatitis B In contrast to declining rates of HCV, the prevalence of chronic HBV in New York City has increased. The DOHMH reported 6,947 newly reported cases in 2023 compared to 5,518 in 2022, and increased its prevalence estimate from 2.9 percent to 3.1 percent citywide. The

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cause of the increase is unknown, but the expansion of testing may at least partially explain the trend. In 2022, the Division pioneered universal one-time HBV screening for adults before the CDC published the same recommendation in 2023, making the MSHS the first U.S. health system to implement this. Mirroring the HCV screening alert, the MSHS team created a health maintenance care gap in Epic that links to a triple-panel order set (HBsAg, HBsAb, and HBcAb). In 2025, the National Committee for Quality Assurance added a new Healthcare Effectiveness Data and Information Set (HEDIS) measure assessing hepatitis B immunization status for persons 19-59 years of age, echoing the 2022 ACIP recommendation. In response, the Division secured approval from MSHS ambulatory and population health leadership to add a vaccination prompt to the HBV care gap for patients whose triple-panel results are negative, indicating lack of immunity. This build is currently underway. HBV screening across the MSHS remained steady between 2024 and 2025, with comparable numbers screened and identified as HBsAg-positive (~1,600 or 1.3 percent of those screened both years) (Figure 2). 917 HBsAg-positive patients were eligible for LEAP outreach in 2025; 690 have received at least 1 outreach attempt to date and 231 have been linked to HBV care. LEAP services for patients with HBV are like those with HCV, with higher usage of interpreter services noted to meet the needs of a more ethnically diverse population. Linkage disparities were found by race, with white and Asian HBV patients less likely to be linked than Black and Latino.

Figure 2. HBV Screening and Care Pathway across the MSHS system in 2025. MSSN was added after their Epic “Go-Live” in late 2025.

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RELINK In mid-2024, the Division secured a new grant from the Center for Disease Analysis Foundation to support strategies aimed at re-engaging diagnosed but untreated patients living with HCV or HBV. The results of the LEAP team’s efforts to chart review and re-link to care patients are illustrated in the RELINK care cascade below.

Figure 3. Re-linkage Cascade for Diagnosed, but Untreated, HCV and HBV Patients

As sub-aims of this initiative, the LEAP team is offering $20 cash incentives to HCV patients who attend their first liver appointment. Though numbers are small, analyses to date show no impact of the cash incentive on appointment attendance. However, patients verbally expressed appreciating the payment. In addition, LEAP initiated a PDSA cycle to assess if making the first outreach attempt via MyChart message instead of phone call would impact linkage rates. Thus far, no difference in appointment attendance was found, but the updated workflow reduced navigator workloads and improved patient trust during subsequent phone interactions. Other Projects MSSN: With Mount Sinai South Nassau’s Epic launch in late 2025, the Division and LEAP team are expanding support services to patients screening positive for HCV and HBV at MSSN and Long Beach. The team has begun collaborating with onsite leadership and is working out referral pathways for patients with different insurance statuses. Hepatitis Delta Virus: To improve the screening rate for this rare but dangerous form of viral hepatitis in the MSHS, the Division enhanced HBV screening with an HBsAg to HDV antibody (HDV Ab) reflex test in 2024. In 2025, the Division collaborated with Labcorp to ensure clinics not using the MSH laboratory also have access to this streamlined screening pathway. In 2025, the Division also collaborated with the ED and OB/GYN to incorporate the reflex test into their standard STI and prenatal panels, respectively. This resulted in >1,000 HBV to HDV reflex tests ordered in the ED between March and May 2025, compared to 170 the prior 12 months, a 23-

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fold increase. The Division is treating 4 HDV patients with expanded-access bulevirtide, with FDA approval of this drug expected in 2026, making this expansion of screening especially timely. In addition, the Division is treating six patients in phase III clinical trials of new drugs for delta hepatitis. MASLD/MASH: The Division collaborated with primary care providers at several clinics to improve screening for advanced fibrosis in patients living with diabetes and referrals to hepatology as needed. Patient navigation to support adherence to the metabolic dysfunctionassociated steatotic liver disease/metabolic dysfunction-associated steatohepatitis (MASLD/MASH) care pathway began in late 2025 and will continue and expand in the new year. PBC: The Division began case finding efforts for patients with primary biliary cholangitis (PBC) in late 2025, which will continue in 2026, paired with outreach to patients who are out of care. The LEAP team hired a new care coordinator to help launch the PBC expansion. This work will be systemwide and will continue in 2026.

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Nephrology

Chronic Kidney Disease Program In 2025, the Division of Nephrology and the Mount Sinai Chronic Kidney Disease (CKD) Program continued to expand its reach across the Health System, now including new practices in the Mount Sinai network. The program utilizes registry data to identify patients with CKD, stratify them by glomerular filtration rate (GFR) and albuminuria levels, and facilitate guidelinebased care.

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2025 CKD Registry Dashboard — Quality Metrics

Table 1. Mount Sinai CKD Registry — Key Quality Metrics, 2025 (Q1 ’25 through Q1 ’26 QTD)

2025 CKD Stage Distribution

Table 2. Mount Sinai CKD Registry — Patient Distribution by CKD Stage, 2025

Compared to 2024, the 2025 data demonstrate gradual, sustained improvements across multiple quality domains. Blood pressure control (≤130/80) improved from 38 percent to 39 percent year-over-year, while A1c ≤8 percent improved from 56 percent to 60 percent. Prescribing of guideline-directed medical therapies also increased: SGLT2 inhibitor use among eligible patients with type 2 diabetes and GFR ≥20 rose from 18 percent to 45 percent, GLP-1 receptor agonist prescribing increased from 24 percent to 37 percent in patients with CKD and diabetes, and mineralocorticoid receptor antagonists (MRA) prescribing improved from 7 percent to 13 percent. ACE/ARB/ARNI prescribing remained stable at approximately 62 percent. The CKD stage distribution reflects a shift toward earlier identification of disease, consistent with expanded outreach efforts. Ongoing efforts are focused on ensuring patients seen across the Health System have care plans aligned with current evidence-based best practices. This includes appropriate follow-up intervals, timely laboratory assessments, and early identification of adverse trends requiring individualized attention. Patients are also screened for contributing conditions such as heart disease and glomerulonephritis. Given the size of the CKD population, risk-stratification tools such as KidneyIntelX continue to play an important role in identifying patients with diabetic nephropathy at highest risk for adverse kidney outcomes.

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KidneyIntelX Risk Stratification Program The KidneyIntelX IRB-approved study evaluates the impact of biomarker-based risk stratification on clinical decision-making, prescribing patterns, and referral decisions in patients with diabetic kidney disease. By late 2025, approximately 9,950 patients had undergone testing, approaching the initial enrollment target of 10,000. The target has since been expanded to facilitate additional data capture. Interim findings were presented at the 2025 National Kidney Foundation Spring Clinical Meeting, demonstrating: •

A proportional increase in SGLT2 inhibitor use correlating with KidneyIntelX risk score— patients in high-risk categories showed the greatest increase in targeted prescribing.

Figure 1. Impact of KidneyIntelX on Targeted Use of SGLT2i in Patients with Diabetic Kidney Disease (NKF Spring Clinical Meeting, 2025)

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Ongoing Challenges and Improvement Strategies Despite measurable improvements, several barriers to optimal CKD care persist: •

Hesitancy among clinicians and patients regarding CKD engagement and diagnosis assignment, particularly for patients with normal or near-normal GFR

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Lack of clarity around coding and diagnosis assignment for early-stage CKD

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Cost and prior-authorization obstacles limiting access to newer therapeutic classes

•

Conversations about kidney disease can be time-consuming and are often deferred due to the perceived remoteness of long-term consequences

Strategies underway to address these challenges include: •

Enhancing communication strategies for early-stage CKD discussions

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Streamlining medication access pathways despite cost and insurance challenges

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Leveraging pharmacy and other systemwide resources to assist point-of-care clinicians

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Increasing renal transplant referrals from the Center for Advanced Medicine clinic, a quality project initiated at the end of 2025

COI Disclosure: KidneyIntelX is an FDA-approved predictive test that combines patient information and biomarker results. KidneyIntelX is based on technology developed by Mount Sinai faculty and licensed to Renalytix, Inc. Mount Sinai faculty and Mount Sinai have equity ownership in Renalytix, Inc. End-Stage Kidney Disease (ESKD) Program In 2025, the Mount Sinai Kidney Center continued to deliver high-quality care to a diverse patient population across all modalities, including in-center hemodialysis, home hemodialysis, and peritoneal dialysis. Mount Sinai Kidney Center at 117th Street and East River Plaza Following the closure of a nearby dialysis facility in late 2024, the 117th Street center assumed care for several dozen patients who transferred on short notice. Many of these patients were dialyzed via tunneled catheters, which temporarily elevated the unit's long-term catheter rate. Ongoing work with patients and vascular surgery partners is focused on transitioning as many patients as appropriate to arteriovenous fistula access. The long-term catheter rate peaked at 19.75 percent in Q2 2024 and has since declined steadily to 12 percent by the end of 2025, reflecting sustained engagement with patients and active planning. Bloodstream infection rates remain very low, a testament to the diligence of the clinical team. Transplant rates continue to outperform state and national averages and represent a particular strength of the program, accounting for a significant fraction of patients who transition off the dialysis census.

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Figure 2. 117th Street Kidney Center — Long-Term Catheter Rate Trend, Q1 2024–Q4 2025. Dashed line indicates national benchmark (10 percent).

Kidney Transplant Referral Standardization at MSMW At MSMW, the Division sought to standardize kidney transplant referral for patients with advanced chronic kidney disease. The increasing prevalence of chronic kidney diseases in stage 4 and end-stage renal disease underscores the importance of early education and referral for kidney transplants, which is associated with improved survival and quality of life compared with dialysis. National guidelines recommend informing and referring patients with CKD stages 4–5 for transplant evaluation at least 6–12 months prior to anticipated dialysis initiation. Baseline assessment within the MSMW Division of Nephrology demonstrated significant variation in transplant-related documentation and referral practices. Only a minority of providers routinely documented kidney transplant discussions, no standardized patient education materials were in use, and transplant referrals were infrequently placed using the designated electronic referral order. The project aimed to increase attendance at initial kidney transplant evaluation visits by 15 percent over one year among adult patients with an estimated glomerular filtration rate of ≤20 ml/min/1.73m² seen at the ACC 6 and Faculty Practice Associates sites at W. 60th Street. Interventions included implementation of a standardized documentation phrase in outpatient nephrology notes capturing transplant referral status and reasons for non-referral, consistent use of the electronic “Amb Refer to Transplant” order for eligible and interested patients, and provision of standardized kidney transplant educational materials in the after-visit summary. Primary outcomes included attendance at transplant evaluation visits and documentation of transplant evaluation status, with secondary outcomes of assessing provision of education and rates of preemptive transplant. Baseline data collection identified patients seen during October– November 2025 with advanced CKD and tracked documentation, referrals, scheduling, and attendance at transplant evaluations. This project will continue in 2026. The Home Dialysis Program at Mount Sinai Kidney Center The home dialysis programs—encompassing peritoneal dialysis (PD) and home hemodialysis (HHD) are co-located with the hemodialysis unit within the main hospital. In addition to hosting Annual Quality and Patient Safety Report

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the nationally recognized 11th Annual Advances in Peritoneal Dialysis Symposium in September 2025, the home programs continue to serve as a cornerstone of the Mount Sinai Kidney Center, ensuring patients have seamless access to all dialysis modalities. Adherence to Quality Recommendations for Dialysis Patients at Mount Sinai Downtown The Division of Nephrology at MSUS also focused its efforts on adherence to quality metrics associated with dialysis. The first project sought to increase the percentage of patients meeting their goal fluid status. The Division improved the percentage of patients with indicators at goal by an average of seven percentage points over the course of the year. The team accomplished this by increasing education of patients on diet and fluid intake as well as offering extra treatments when indicated. Adjusting the dry weight orders and ensuring fluid algorithms were ordered on admission and followed during treatments was important as well. Another Division goal was to improve the percentage of attended dialysis treatments. Studies show that missed dialysis leads to increased hospital admissions. To improve these metrics, the Division worked on increasing communication and education. The team made frequent phone calls to patients who missed treatment, especially on the day of the missed treatment. These efforts led to an average of 10 percent improvement in patients attending their treatment appointments. The Division at MSDUS also renewed its focus on increasing the percentage of patients who have an access other than catheter after 90 days on dialysis. KDOQI guidelines now advise the Patient First – End Stage Kidney Disease Life Plan, which involves increased discussion about dialysis access based on the individual patient. Thus, increased efforts were placed on education and communication and early referral to the access teams. With these interventions, the percentage of chronic hemodialysis patients with preferred access increased by about 2 percent over the year. Central Line-Associated Bloodstream Infection (CLABSI) Among Inpatient Dialysis 2025 represented a successful year for inpatient dialysis CLABSI reduction at MSH. The total number of inpatient events declined to 10—fewer than one event per month, which is the lowest annual total in the program’s recorded history. No specific changes to line care policy or procedure were implemented; improvement is attributed to increased diligence among floor teams in monitoring dressing conditions and promptly escalating any concerns identified.

Table 3. Inpatient CLABSI in Patients Receiving Kidney Replacement Therapy, 2020–2025 (through Nov 2025). Includes NonTunneled Catheter (Non-TC), Tunneled Catheter (TC), CVVH, and Transplant categories.

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Nephrology and dialysis nursing continue to participate in all dialysis CLABSI huddles and collaborate with infection prevention and key stakeholders to identify risk factors and implement sustainable reduction strategies. Reducing inpatient catheter days remains a central objective. Outpatient dialysis facilities and CKD clinics continue efforts to ensure arteriovenous access is in place prior to hospitalization, which both reflects best practice and reduces catheter-days when patients are admitted. As noted in the ESKD section, the census at 117th Street increased substantially over the year following the absorption of patients from a nearby closed center, including several who were dialyzed via tunneled catheters. The facility continues to work with patients and vascular surgery partners to facilitate timely transition to non-catheter access, which should further reduce the number of inpatient line days. Nephrology Outpatient Follow-Up After Inpatient Consultation at MSMW The Division at MSMW also focused on improving outpatient nephrology follow-up after inpatient consultation, recognizing that timely follow-up improves care transitions and, in patients with severe acute kidney injury, has been associated with lower all-cause mortality. Prior to intervention, particularly during evenings and weekends, outpatient referrals were placed inconsistently through multiple workflows, leading to delays, inappropriate referrals, and missed follow-up opportunities. The project aimed to increase 90-day outpatient nephrology follow-up rates by 15 percent over one year for patients seen by the inpatient nephrology consult service at MSM and MSW. Key interventions included educational outreach to internal medicine residents, social workers, and discharge coordinators regarding appropriate referral indications, and implementation of a standardized documentation phrase in nephrology consult notes specifying whether outpatient follow-up was recommended, the desired timeframe, and whether follow-up would occur in clinic or at a dialysis unit. The intervention also emphasized requesting notification at least 48 hours prior to discharge to facilitate appointment scheduling. Primary outcomes included attendance at an outpatient nephrology visit within 90 days of discharge, with a secondary outcome of the frequency of appointments scheduled prior to discharge. Baseline data from October–November 2025 demonstrated that among patients seen by the nephrology consult service, outpatient follow-up recommendations were inconsistently documented, appointments were not reliably scheduled prior to discharge, and attendance rates were higher when appointments were arranged before discharge. This work will also continue in 2026.

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Pulmonary, Critical Care and Sleep Medicine

In 2025, the Division of Pulmonary, Critical Care, and Sleep Medicine at The Mount Sinai Hospital, Mount Sinai West (MSW), Mount Sinai Morningside (MSM), and the Respiratory Institute at Mount Sinai-Downtown continued collaborative efforts on various quality projects that encompassed both inpatient and outpatient practices. Chronic Obstructive Pulmonary Disease Readmissions Reduction Program Chronic obstructive pulmonary disease (COPD) is the third leading cause of 30-day readmissions among Medicare patients. Approximately 20 percent of patients admitted for an acute exacerbation of COPD will be readmitted within 30 days. The Division was actively involved in a systemwide standardization of COPD care initiative, which introduced many protocols and templates based on best practices and evidence-based data. The goal of these initiatives was to optimize COPD management and improve the quality of care and safety of patients admitted with COPD. Identifying patients admitted with an acute exacerbation of COPD

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(AECOPD) in real time facilitates the necessary multidisciplinary care of these patients to optimize their inpatient management and reduce the risk of a potential readmission. The Division, working closely with Clinical Integration at the Mount Sinai Health System, introduced a COPD care bundle to MSM and MSW, which aimed to optimize the management of admitted patients with AECOPD and reduce avoidable readmissions. COPD admissions appear on an Epic COPD list and receive multidisciplinary care via the COPD pathway from Respiratory Therapy, Pharmacy, Social Work, and the Pulmonary Consult team. Within 72 hours of discharge, the patient receives a call from the Transitions of Care team and attempts are made to provide a pulmonary outpatient clinic appointment within 14 days post-discharge. The patient may be referred to pulmonary rehabilitation, smoking cessation counseling, and palliative or hospice care. There was an increase in the number of patients with AECOPD who were followed on the COPD pathway at MSW (from 46.2 percent in 2024 to 55.0 percent in 2025) and at MSM the rate remained stable (from 43.6 percent in 2024 to 43.5 percent in 2025). The COPD readmission rate at MSW decreased from 21.1 percent in 2024 (O/E 1.51) to 14.4 percent in 2025 (O/E 1.00). At MSM, the COPD readmission rate increased from 17.3 percent in 2024 (O/E 1.24) to 18.7 percent in 2025 (O/E 1.35). Of note, the systemwide COPD readmission rate was 19.8 percent in 2025 (O/E 1.45). Readmissions will be a high priority in 2026. The 30-day COPD mortality rate at MSW decreased from 2.3 percent in 2024 to 2.2 percent in 2025, and at MSM, the 30-day mortality rate decreased from 2.3 percent in 2024 to 1.1 percent in 2025. The Division also sought to reduce the wait time for discharged patients to be seen in the outpatient pulmonary clinic. COPD admissions are prescribed varenicline to minimize nicotine withdrawal and facilitate smoking cessation. Varenicline is prescribed at the time of discharge to enable the patient to continue its use as an outpatient. The Division also increased utilization of the smoking cessation order set that incorporates varenicline. With the support of Respiratory Therapy, there was also increased use of spirometry. There was also a multidisciplinary effort to identify frequent utilizers with the aim of addressing both the drivers of readmission and identifying barriers that increase the risk of COPD readmissions. During 2025, MSH also participated in the systemwide COPD care standardization efforts, with review of 30-day COPD readmissions, patient-level drivers of readmission, and care standardization metrics through August 2025. COPD readmission trends were reviewed using Tableau dashboards and compared with prior-year performance. Service line care standardization metrics highlighted discharge bundle components, including completion of follow-up appointments within 30 days and prescription of varenicline at discharge, the latter reflecting the recent addition of Chantix to the COPD pathway order set. Patient-level readmission review from June through August 2025 identified seven readmissions, largely among medically complex patients with multiple comorbidities, frequent exacerbations, or barriers to post-acute care, including lack of access to prescribed respiratory support in skilled nursing facilities. Case review suggested variability in outpatient pulmonary follow-up, vaccination status, and smoking cessation pharmacotherapy. In addition, an observational study was outlined evaluating dupilumab use in eosinophilic COPD patients with lung nodules to assess impact on COPD severity, inflammatory markers, and lung cancer risk, with planned longitudinal data collection and provider outreach to identify eligible patients.

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Identifying Provider Gaps in Optimizing Lung Transplant Referrals in a Pulmonary Fellowship Outpatient Clinic at MSMW and MS Downtown Lung transplant referral remained a critical gap in care for patients with advanced lung disease, influenced by both patient-level clinical presentations and provider-level knowledge gaps regarding criteria for lung transplant referral and the process of referral. To address this, the Pulmonary and Critical Care Fellowship Program conducted a multi-phase quality improvement initiative aimed at identifying and closing provider gaps in lung transplant referral practices within the fellows’ outpatient continuity clinic. Following an initial needs assessment that demonstrated low rates of transplant discussion and referral among eligible patients, a targeted educational intervention was implemented focusing on disease-specific referral criteria and the local transplant referral process. Post-intervention surveys showed improved fellow knowledge and confidence regarding lung transplant referrals, and a retrospective chart review was conducted to assess real-world changes in clinical practice and identify persistent barriers to appropriate referrals. Post-intervention analysis demonstrated meaningful improvement in identifying a potential transplant candidate, with discussion rates with the candidate increasing from 25 percent to 52.6 percent and referral rates rising from 12.5 percent to 26.3 percent among eligible patients (see below). However, ongoing provider gaps were revealed, particularly in recognizing clinically stable but high-risk candidates, including patients with pulmonary fibrosis and those with chronic obstructive pulmonary disease and elevated BODE (Body Mass Index, Airflow Obstruction, Dyspnea, Exercise Capacity) scores. Eighteen of 38 eligible patients (47 percent) were not referred for lung transplant: 6 were active smokers, 2 declined referral, and 10 were not referred due to clinical concerns, including low BODE scores (4 patients) and advanced pulmonary fibrosis (6 patients). Notably, first-year fellows did not discuss transplant eligibility with any patients who met lung transplant criteria despite receiving the same educational intervention as senior trainees. The study findings highlight the need for continued and more structured education, standardized referral criteria, and earlier incorporation of transplant education in pulmonary fellowship training. Future efforts will focus on reinforcing objective risk stratification tools using EMR prompts, clarifying referral thresholds for interstitial lung disease, and tailoring educational strategies to trainee level to promote timely, equitable lung transplant referral. Pre- and Post-Intervention Analysis Regarding Identification of Lung Transplant Candidates

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Utilizing Patient Portal Check-In to Automate Asthma Control Test Scoring Guideline-recommended patient-reported outcome measures, such as the Asthma Control Test (ACT), are critical for assessing asthma control but are frequently underutilized in routine ambulatory care due to workflow and documentation barriers. To address this gap, the Division at the Respiratory Institute implemented an electronic medical record (EMR)–integrated ACT embedded directly into the patient portal pre-visit check-in process across multiple outpatient pulmonary clinics. Completed ACT responses were captured in a structured flowsheet and made immediately available to clinicians through standardized documentation tools, enabling real-time use during the clinical encounter. Providers were notified of the new workflow and encouraged to incorporate ACT results into assessment and decision-making, with the goal of increasing standardized asthma control assessment without adding clinical burden. The patient characteristics of the adult asthma visits are demonstrated below. Following implementation, ACT documentation increased from 12.3 percent to 28.9 percent of adult asthma visits, representing a 2.35-fold relative improvement. This early impact was observed in an older, socioeconomically diverse patient population with high patient-portal activation, demonstrating the feasibility of portal-based patient-reported data capture at scale. While overall ACT completion remains below guideline targets, this initiative established a low-burden, reproducible framework for integrating patient-reported outcomes into routine care using existing digital infrastructure. Future improvement cycles will focus on expanding equitable access through multilingual prompts, point-of-care portal activation, and alternative data-capture methods for non-portal users, as well as linking ACT results to treatment adjustments and outcomes to drive sustained improvements in asthma care quality.

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Prescription Behavior Changes Among Pulmonary Physicians After Climate Change Education Air pollution, longer pollen seasons, and extreme temperature shifts in climate change have been linked to increased incidence of asthma and chronic obstructive pulmonary disease (COPD) exacerbations. Hydrofluorocarbon (HFC) propellant used in metered dose inhalers (MDIs) is a potent greenhouse gas and contributes to climate change. Alternative forms of medication delivery such as dry powder inhalers (DPIs) have been found to have a greater than 10 times lower carbon footprint than MDIs and are proven to be non-inferior to MDIs in the management of asthma in adults. The study evaluated prescription practices of pulmonary providers at the Respiratory Institute and MSM pulmonary clinics after educational intervention on the impact of climate change on respiratory health. A chart review was performed of 96 outpatient encounters pre-intervention and 143 outpatient encounters post-intervention. Outpatient encounters were selected based on chart-based diagnosis of asthma, COPD, or other suspected obstructive diseases. Available pulmonary function tests and insurance at the time of the encounter were also reviewed. No appreciable differences were noted in prescriber behavior practice after intervention. Prescription rates of HFC and DPI inhalers for maintenance therapy were comparable: Before intervention, 42 percent of all inhalers were HFCs and 37 percent were DPIs, and after intervention, 42 percent were HFCs and 41 percent were DPIs. The most popular initial choice of maintenance inhaler therapy remained an HFC inhaler (36 percent before intervention and 47 percent after intervention). In the investigated patient population, most patients had Medicaid or Medicare or managed Medicaid or Medicare insurance, accounting for 75 percent of all evaluated patients. For three patients, insurance coverage was a driver for a prescribing change

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in inhaler type. Change in asthma control was cited as the most common reason for change in inhaler (71 percent). Despite effective educational intervention, prescription behavior changes in favor of more climate-conscious inhalers were not seen among pulmonary physicians. Notably, there were possibly many uninvestigated variables that could have accounted for this lack of change, including not only risk versus benefit discussions in changing patient’s inhalers when the patient’s disease was well controlled as well as the lack of specific DPI formulations within the United States. The choice of maintenance inhaler was guided by multiple competing factors. Pulmonary Embolism Response Team (PERT) Outcomes Data The Division sought to improve outcomes for patients with pulmonary embolism (PE) through use of the Pulmonary Embolism Response Team (PERT). PERT is a multidisciplinary team of pulmonologists, cardiologists, cardiothoracic surgeons, and interventional radiologists who co-manage patients with acute massive and submassive PE. The program provides an infrastructure to deliver rapid input from these experts to optimize and streamline treatment. PERT activation at Mount Sinai Beth Israel (closed in March 2025), MSW, and MSM was responsible for the management of 78 patients in 2019, 88 patients in 2020, 47 patients in 2021, 82 patients in 2022, 95 patients in 2023, 77 patients in 2024, and 49 patients to date (January 1, 2025 to October 31, 2025). With respect to the 2025 data, using the European Society of Cardiology (ESC) classification, 1 percent, 0 percent, 57.14 percent, and 40.82 percent were low risk, intermediate low risk, intermediate high risk, and high risk, respectively, for PE mortality. Forty percent of acute PE patients had a concurrent DVT. Advanced therapies for PERT-managed patients in 2025 included catheter-directed thrombolysis (4.1 percent), catheter-directed embolectomy (10.2 percent), and placement of an inferior vena cava filter in 12.24 percent of patients. Outcomes of PERT-managed acute PE patients are represented below. Outcomes of Acute PE Patients Managed by PERT (n=49) January to October 2025

Causes of 30-day mortality in 20.41 percent of patients (n=10) included: high-risk PE (n=6, 60 percent), concurrent severe sepsis (n=1, 1 percent), and malignancy (n=1, 1 percent). Major bleeding occurred in 4 patients (8.1 percent) where causes included upper GI bleed (n=3) and D.I.C. (n=1). The readmission rate at 30 days was 8.1 percent (n=4), secondary to recurrent PE or DVT (n=2), CVA (n=1), and peripheral vascular disease (n=1). Thirty-six patients (73.47 percent) followed up in the Mount Sinai Health System with Mount Sinai Internal Medicine or at a pulmonary outpatient clinic.

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The 2026 aims include implementing a protocolized, evidence-based template for outpatient management in the MSM Venous Thromboembolism Clinic, with systematic evaluation and longitudinal follow-up of post-pulmonary embolism quality of life using a validated questionnaire. The Division will follow several outcomes including venous-thromboembolism recurrence rate, complications from anticoagulation treatment, the incidence of post-PE persistent shortness of breath, and the development of chronic thromboembolic pulmonary hypertension. The systemwide PERT conferences to review PERT outcomes data, discuss new literature pertaining to acute PE management, and share ongoing PE-related research projects will also continue Sleep Program: Increasing Access to Sleep Testing at MSH The demand for sleep testing in the community and within the Mount Sinai Health System (MSHS) remains high. Top referral indications include sleep disordered breathing such as obstructive sleep apnea (OSA), respiratory failure/hypoventilation, central sleep apnea (CSA), and non-respiratory sleep disorders such as hypersomnia, insomnia, and sleeprelated movement disorders. In 2025, the sleep program continued efforts to improve access to sleep testing. The sleep lab, located at New York Eye and Ear Infirmary of Mount Sinai with a total capacity of 11 polysomnography studies per night, is accredited by the American Academy of Sleep Medicine (AASM) and serves as the largest sleep testing center in the Health System. In 2025, collaborative efforts with the in-lab facility at Mount Sinai South Nassau as well as the pediatric sleep lab located in Kravis Children’s Hospital continued to standardize and expand the sleep testing network for patients in the Health System across the age spectrum. Interventions included expansion and standardization of home test sites and procedures, sleep technologist recruitment and training, workflow optimization to reduce study authorization, dispensing, and reporting of completion times. The Division saw continued growth in overall sleep study volume and reduction in sleep study completion time. Home study volumes grew by 11 percent with a total of 7,248 studies completed in 2025; in-lab volumes grew by 16 percent with a total of 2,785 studies.

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Time from Order to Study Completion

The Division also started a new initiative to establish a standardized process to incorporate tirzepatide, which received FDA approval for moderate-to-severe OSA in patients with BMI ≥ 30, into the treatment program for OSA. To date, this new therapeutic option was prescribed to 238 patients, with 30 percent of patients achieving a dose of tirzepatide 10 mg by December 2025. The program will continue to expand in 2026 to ensure comprehensive lifestyle and weight management services can be provided to patients alongside OSA pharmacotherapy. Other initiatives that were continued in 2025 include: •

REM behavior disorder study quality optimization: Focus on EMG signal acquisition on in-lab sleep studies.

•

Patient satisfaction: Q reviews continued to show consistently positive scores on patient experience with sleep testing. Individual patient concerns are addressed through individual outreach, and the sleep team incorporates issues identified via feedback into regular safety and process improvement efforts.

Bronchoscopy The Division continued efforts to improve outcomes in patients undergoing bronchoscopy, especially in American Society of Anesthesiologists (ASA) physical status classification system III & IV level patients. Bronchoscopy volume remained steady in 2025 with a total procedural volume of 1,314. The proportion of ASAIII & IV level patients represented 97 percent of all bronchoscopy cases performed, like the prior year. The number of complications associated with 2025 bronchoscopies was 11 (1 percent), a sustained low rate compared with prior years. All cases with complications are reviewed, and corrective actions are implemented where appropriate.

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The booking process for inpatient bronchoscopy cases was standardized with the reinforcement of clinical information documentation and pre-procedure IP/pulmonary team assessment, as well as automated team-wide communication between Endoscopy and IP. A pre-procedure history and physical examination SmartPhrase contained the procedure planned, patient respiratory or other clinical concerns, transfusion requirements before procedures, and medications. The Division also continued to utilize a QR code for inpatient scheduling that links to a menu-driven questionnaire, which generates an automated email upon submission to the inpatient team, pulmonary administrative assistant, endoscopy front desk, and endoscopy nursing leaders. This initiative helped to ensure that patients are scheduled properly and transported safely.

Rheumatology

The Division of Rheumatology at The Mount Sinai Hospital and Mount Sinai Morningside West is committed to delivering exceptional, patient-centered care while driving continuous quality improvement. This section highlights key initiatives undertaken during the past year that focus

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on biologic therapy monitoring, improving vaccination rates, integrating disease activity scoring, and enhancing cardiovascular screening for rheumatic patients. Screening and Health Maintenance for Patients on Rheumatologic Medications The Mount Sinai Hospital Rheumatology Division sought to increase the rate of tuberculosis (TB) screening for patients on biologics, in accordance with a Centers for Disease Control and Prevention (CDC) recommendation to screen before initiating biologics and annually if on anti-TNF medications. The Division improved performance by distributing quarterly providerspecific scorecards to promote individual improvement. The Division also sought to increase utilization of a health maintenance SmartPhrase that was added to Epic in late 2020 that facilitated viewing and documenting TB screening status. These interventions have been successful, nearing the goal of 90 percent, and will continue into 2026.

The Division also continued a project to increase rates of pneumococcal vaccination for patients on biologics at MSH. Baseline rates of pneumococcal vaccination in 2021 were low, with only 23 percent of patients on biologic medications receiving any pneumococcal vaccine. The Division implemented a multidisciplinary intervention that involved generating lists of patients scheduled to be seen each week who have not yet received the vaccine and registered nurses reminding providers, both in person and through Epic, about the vaccine for eligible patients at the time of the appointment. Since these interventions were implemented in 2022, rates of pneumococcal vaccination have increased to 58 percent. The Division will continue these efforts in 2026 with the goal of increasing the rates to at least 75 percent by the end of the year. In addition, the Division plans to implement additional patient-facing reminders through MyChart to further enhance patient engagement, as well as to involve other MSHS sites in this endeavor. The Division at MSH also sought to increase the rate of annual ophthalmologic exams for patients taking hydroxychloroquine (Plaquenil) to 90 percent. This is a critical measure because Plaquenil may cause irreversible retinal damage, and early detection is the key to prevention. In 2025, a survey and flowsheet were created to help collect data on patients who receive their ophthalmologic care at other institutions. The survey is automatically sent to patients via MyChart and allows the Division to more accurately collect data and identify patients who are overdue for their exams.

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The Division was able to improve the ophthalmologic screening rates to 87 percent over the course of 2025 from a baseline of less than 70 percent at the beginning of 2024. These efforts will continue in 2026 to achieve a goal rate of 90 percent. Ophthalmologic Exam for Patients on Hydroxychloroquine at MSH 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Q1 2024

Q2 2024

Q3 2024

Q4 2024

Actual

Goal

Q1 2025

Q2 2025

Incorporation of Clinical Disease Activity Index into Routine Patient Evaluations The Mount Sinai Morningside and West Division of Rheumatology aimed to systematically incorporate Clinical Disease Activity Index (CDAI) scores into routine patient evaluations. Analysis using Epic’s Slicer/Dicer tool revealed that CDAI score usage from January to June 2024 was below 60 percent due to provider variation in disease activity measurements. To address this discrepancy, the Division developed and implemented an Epic smart list feature to streamline CDAI documentation. Providers received quarterly performance feedback on their CDAI utilization rates. To date, the usage of the smart list has increased more than 50 percent from baseline, exceeding the goal of more than 20 percent. This standardized approach will enable more precise assessment of inflammatory conditions, particularly rheumatoid arthritis, while helping identify patients at higher risk for disease progression or adverse outcomes. Screening and Prevention of Cardiovascular Disease in Patients with Rheumatic Diseases Cardiovascular disease (CVD) is one of the leading causes of mortality in patients with rheumatic diseases due to increased systemic inflammation, which accelerates atherosclerosis. Rheumatologists at MSMW conducted a provider study across all Mount Sinai rheumatology sites to identify key care gaps in cardiovascular screening and counseling. The Division sought to address these gaps through educational information sessions for rheumatology providers and internal medicine residents, and educational pamphlets for patients. A data review of 365 patients at the 425 W. 59th Street clinic location revealed that more than 40 percent had neither a HbA1c nor LDL cholesterol checked within the past year, representing a significant missed opportunity for CVD risk detection. This project will continue in 2026 with an aim to increase LDL screening by creating an Epic best practice alert and enhancing PCP referral pathways.

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Smoking Cessation in Rheumatology Clinics Another QI project sought to enhance smoking cessation interventions in patients with inflammatory arthritis at three and six months and included 146 eligible patients at MSMW. Interventions such as sticky note reminders, provider emails, and brochures in clinics were utilized. Data was analyzed with McNemar’s test, focusing on discordant pairs. A statistically significant improvement in smoking cessation intervention offered by providers was observed at six months compared to three months overall (24 percent compared to 76 percent), when stratified by gender (male and female), and in Hispanic/Hispanic female populations. This project highlighted the effectiveness of utilizing widespread smoking intervention campaigns and the need to continue the initiative. Creation of an Epic order set is underway and will include starter and maintenance dose one-click prescriptions of medications to reduce tobacco use and a referral to the MSM smoking cessation clinic

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Publications, Presentations, and Grants The Mount Sinai Downtown Publications Koseki Senda, M., Chow, D., Dev, B., DeBroff, J., O’Ferrall, C., Fliehman, R., & Jiang, R. (2025). Improving colorectal cancer screening through Cologuard education: a quality improvement initiative in an urban primary care clinic. BMJ Open Quality, 14(4), e003553.

The Mount Sinai Hospital Publications Gastroenterology Dev B, Hadi Y, Rizvi A et al. Low Rates of Aborted Endoscopy Due to Gastric Food Retention in Patients on Glucagon-Like Peptide-1 Receptor Agonists. Dig Dis Sci. 70, 1838–1843 (2025). https://doi.org/10.1007/s10620-025-08915-1 Gore E, Cytryn E, Leven E, Chen A, Beah P, Glasser A, El Haj S, Cao C, Greenwald D. Use of a Pre-Procedural Checklist to Improve Percutaneous Endoscopic Gastrostomy (PEG) Consult Workflow. The American Journal of Gastroenterology. 120(10S2):p S640, October 2025. | DOI: 10.14309/01.ajg.0001139372.64706.fd Infectious Diseases Margolis M, Vasishta S, Aberg J, Urbina A, Dieterich D, Mullen M, Chasan R. A Quality Improvement Pilot to Increase Hepatitis B Screening and Optimize Patient Selection for Switch to Two-Drug Antiretroviral Regimens in People with HIV. Open Forum Infect Dis. 2025 Oct 19; ofaf638. Liver Medicine Mageras A, Rodriguez N, Katzenstein C, Lee F, Alpert L, Branch AD, Zhang X, Dieterich DT, Kushner T. Novel Implementation of Hepatitis B to Hepatitis Delta Reflex Testing in a US Healthcare System. Am J Gastroenterol. 2025 Jul 31. doi: 10.14309/ajg.0000000000003688. Katzenstein C, Mageras A, Rodriguez N, Lee F, Alpert L, Branch AD, Zhang X, Dieterich DT, Kushner T. Translating Hepatitis D Virus Screening Cost-Effectiveness into Practice: The Case for Reflex Testing in the United States, Clinical Infectious Diseases, 2025; ciaf324, https://doi.org/10.1093/cid/ciaf324

The Mount Sinai Hospital Presentations (Abstracts and Workshops) Clinical Immunology Ye C. Practical Approaches to Drug Hypersensitivity: Managing Diverse Populations and RealWorld Challenges [Education Program]. American College of Allergy, Asthma & Immunology. November, 2025. Phoenix, AZ.

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Hospital Medicine Canas A., Kochar A., Linker A. Sweet Notes and Sugar Shifts: Updates in Diabetes Management for the Hospitalist. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Nguyen V, Cheung P. Updates in Gastroenterology. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Hernandez K, Engles B, Gluth A, Niranjan-Azadi A. Walk the Line: Effective Communication During Challenging Patient Encounters. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Nguyen V, Kochar A, Raucher B, Fondahn E. Closing the Loop: Empowering Clinicians Through Safety Event Reporting. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Cedeno N, Markoff B, Hernandez K, Singh V. Three Attendings, Two Weeks, One Solution: The Educational Feedback Huddle. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Dunn A. When Less Is More: How to Provide Less Anticoagulant and Antiplatelet Treatment to Improve Outcomes. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Diamond-Pott H, Langer K, Silver-Beck N, Anemelu E, de Oliveira S, Cumai C, Avillo M, Kaur A, Dempsey B, Pearson JM, Ondrush N, Chasan R, Nguyen VT, Linker AS, Kim D, Lin D. Culture Change: De-escalating From Intravenous to Oral Antibiotics [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Diamond-Pott H, Langer K, Silver-Beck N, Anemelu E, de Oliveira S, Cumai C, Avillo M, Kaur A, Dempsey B, Pearson JM, Ondrush N, Chasan R, Nguyen VT, Linker AS, Kim D, Lin D. Culture Change: De-escalating From Intravenous to Oral Antibiotics [Poster Abstract]. Society of General Internal Medicine. May, 2026. Washington, DC. Diamond-Pott H, Langer K, Silver-Beck N, Anemelu E, de Oliveira S, Cumai C, Avillo M, Kaur A, Dempsey B, Pearson JM, Ondrush N, Chasan R, Nguyen VT, Linker AS, Kim D, Lin D. Culture Change: De-escalating From Intravenous to Oral Antibiotics [Poster Abstract]. American College of Physicians. April, 2026. San Francisco, CA. Fish A, Nguyen V. Less Is More: Redesigning Documentation to Reduce Note Bloat. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Iyer S, Pearson JM, Ash N, Dempsey B, De Britto S, Raucher B, Nguyen VT. Less Pajama Time and More Sleep: Improving Inpatient Text Communication. [Poster Abstract]. Society of Hospital Medicine. April, 2025. Las Vegas, NV. Kochar A. How to Lead a Debrief After a Patient Death or Adverse Event. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Tejiram R, Dunn A, Gownivaripally P, Shneyderman M, Sawant A. Peri-Operative DOAC Protocol Adherence: Don’t Set It and Forget It. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN.

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Tejiram R, Scott M, Vezina M, Beilin Y, Nguyen V. Smarter Sedation: Evaluating a Minimal Sedation Protocol for Inpatient MRI. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Liver Mageras A, Debroff J, Jeon J, Hussein R, Rosa T, Bass I, Gold C, Wang S, Mack T, Chow D, Priven N, Viola H, Zhang X, Carnavali F, Bansal MB. MASLD/MASH Care Pathway Adherence Identifies Patients with Advanced Fibrosis. [Poster Abstract]. American Association for the Study of Liver Diseases’ The Liver Meeting. November, 2025. Washington, DC. Nephrology Tokita J, Shivani R, Donovan M, Suarezfarinas M, Lam D. Impact of KidneyIntelX on Targeted Use of SGLT2i in Patients with Diabetic Kidney Disease. [Poster Abstract]. 2025 National Kidney Foundation Spring Clinical Meeting. April, 2025. Boston, MA.

The Mount Sinai Hospital Grants/Awards General Medicine Kutscher, E, Halket D, Blum, C., Koransky, A., Fishman, M. Improving Clinic Documentation and Efficiency with Problem-Based Charting and Use of a Standardized Note Template. The Office of Well-Being and Resilience (OWBR) Faculty Grant. Liver Medicine Dietrich, D. RELINK to Care for Patients Diagnosed but Untreated with HBV and HCV. Center for Disease Analysis Foundation. General Medicine Bryant, K. B. Uncontrolled Hypertension in Young Adults: A Real-World Analysis [Poster Abstract]. Journal of General Internal Medicine, 40(Suppl 1). Society of General Internal Medicine Annual Meeting. May 2025. Hollywood, FL. Bryant, K. B., & Abdalla, M. Clinical Updates in Cardiovascular Risk Factors [Workshop]. Society of General Internal Medicine (SGIM) 2025 Annual Meeting, Hollywood, FL. Bryant, K. B., Barai, N., Islam, S., Feinberg, A., Cluett, J. L., & Young, E. Last recorded blood pressure measurement as a proxy for average blood pressure control (Poster Abstract). Journal of the American College of Cardiology, 85(11_Suppl). American College of Cardiology Annual Scientific Session Presentation. March 2025. Chicago, IL.

Mount Sinai Morningside and Mount Sinai West Publications Hospital Medicine Pearson J, Keller K, Veldboom E, Waite H, Reiff-Pasarew F (2025). Tackling Throughput with a Novel Care Team Rounding Model. Patient Safety. 2025 Apr 3;7(2).

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Mount Sinai Morningside and Mount Sinai West Invited Presentations Hospital Medicine Fox L. (2026). Grand Rounds: Quality Improvement in Action. Mount Sinai Morningside West Department of Medicine Grand Rounds. April 8, 2026.

Mount Sinai Morningside and Mount Sinai West Presentations (Abstracts and Workshops) Hospital Medicine Burger A, Roberts M. Updates in Clinical Guidelines. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Psomadakis C, Shenoy S. AKI and CKD Management. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Abraham J, Singh V, Markoff B, Maresky L. A Pocket of Untapped Potential: Shifting Paradigms in Procedural Competency. [Poster Abstract]. Society of Hospital Medicine. April, 2025. Las Vegas, NV. Abraham J, Singh V, Maresky L (2026). A Secure Chat-Based Pairing Model Doubled Paracentesis Certifications in Four Months. The Hospitalist. Jan 26; 30(1) 18-19. Hui J, Dharapak P, Sawant A, Shenoy S, Saravanan V, Silverstein A, Levy S, Muller S, Yashaev V, Sikorski C, Zaretsky I. Nudging Safer Prescribing: A Best Practice Advisory to Reduce Morphine Use in Patients with Renal Impairment. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Parikh F, Shenoy S, Shim A, Kaur G, Markoff B, Winston E, Usherenko I. Advancing Care Through Collaboration: A Pharmacy Technician Education Program to Improve Medication Reconciliation on Admission. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Saravanan V, Fleming C, Garry E, Elias E, Rivadeneira Cabezas E, Shenoy S, Yang Z, Zaretsky I. “Let Me Go!”: Are We Missing Key Elements in Capacity Evaluations for Patients Leaving Against Medical Advice? [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Ramachandra S, Rothman A. Running a Code: Cardiac Arrest for the Rising Senior. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Velo A, Cedeno N, Shenoy S, Chen N, Abdel Qader F, Hernandez K, Singh V. Bringing Structure to the Medicine Consult Rotation: A Hybrid Curriculum. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Reznik M, Velo A, Dharapak P. (2026) A Resident-led Ultrasound-Guided Peripheral IV Team Improves Resident Work-Related Quality of Life. Mount Sinai Health System Department of Medicine Research Day, May, 2026. New York, NY.

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Mount Sinai Morningside and Mount Sinai West Grants/Awards Hospital Medicine Parikh F. Advancing Care Through Collaboration: A Pharmacy Technician Education Program to Improve Medication Reconciliation. The Office of Well-Being and Resilience (OWBR) Faculty Grant.

Mount Sinai Hospital at Home Publications Truong T, Siu A. Scaling Hospital at Home beyond the original studies. JAMA Netw Open. 2025;8:e2510622. 10.1001/jamanetworkopen.2025.10622. Penn M, Epstein J, Ha J, Wajnberg A, Siu A, Truong T. Serving the neighborhood: insights into Hospital at Home demographics. J Am Geriatr Soc. 2025;10.1111/jgs.70062.

Mount Sinai Hospital at Home Presentations (Abstracts and Workshops) Epstein J, Truong T. Embedding Hospital at Home into Health System Operations: Leveraging a Clinical Command Center. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Epstein JD, Nissel A, Rizk D, Zafar S, Zaretsky I, Truong T. A unique approach to patient identification for a hospital at home service. Poster presented at: SHM Annual Meeting, San Diego, CA. April, 2025. Epstein J, Truong T, Murphy S, Paulson M. Hot Chicken and Hot Cases: From Mild to Wild on Hospital at Home. [Workshop]. Society of Hospital Medicine. March, 2026. Nashville, TN. Epstein JD, Truong T, Wajnberg A. Lessons from surge: home-based programs can be leveraged to meet the needs of stressed hospital systems. Poster presented at: SHM Annual Meeting, San Diego, CA. April, 2025. Epstein J, Wajnberg A, Huprikar S, Truong T. Hospital at home improves patient quality, experience and expands hospital capacity. Poster presented at: Vizient Summit, Las Vegas, NV. September, 2025. Epstein JD, Zaretsky I, Cole K, Zeleke H, Truong T. Does a hospitalization at home service provide age-friendly care? Poster presented at: SHM Annual Meeting, San Diego, CA. April, 2025. Penn M, Epstein JD, Ha JE, Wajnberg A, Siu AL, Truong T. Serving the neighborhood: insights into hospital at home demographics. Poster presented at: SHM Annual Meeting, San Diego, CA. April, 2025. Penn M, Epstein JD, Ha JE, Wajnberg A, Siu AL, Truong T. Demographic analysis of reasons for non-enrollment into hospital at home. Poster presented at: SHM Annual Meeting, San Diego, CA. April, 2025.

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Truong T. How to Build and Scale a Successful Hospital at Home – the New Normal for Hospital Medicine. [Workshop] Society of Hospital Medicine Annual Conference – Converge. April, 2025. Las Vegas, NV. Snyder G, Truong T, et al. Building organizational resilience for hospital at home: addressing burnout for clinical operational leaders. Poster presented at: American Academy of Home Care Medicine Annual Meeting, New Orleans, LA. October, 2025. Truong T, Wang L, Jackson B, Epstein J. Turning Up the Volume on Value: Leveraging Elastomeric Pumps to Expand Hospital at Home Access. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Yunez S, Epstein J, Zaretsky I, Cole K, Ha J, Schwartz L, Truong T. Age-Friendly Care on Hospitalization at Home: Home Is Where the 4Ms Are. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN. Zafar S, Zaretsky I, Collazo B, Epstein JD, Truong T. Subspecialty consult utilization in hospital at home. Poster presented at: SHM Annual Meeting, San Diego, CA. April, 2025. Poster competition finalist. Zaretsky I, Epstein JD, Zafar S, Truong T. Establishing a hospital at home educational curriculum for medical trainees. Poster presented at: SHM Annual Meeting, San Diego, CA. April 2025. Zaretsky I, Epstein J, Zafar S, Collazo B, Truong T. Hospital at Home (HaH) Elective: Impact on Trainee Familiarity, Confidence, and Engagement with the HaH Model. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN.

Mount Sinai Hospital at Home Invited Presentations Truong T. Hospital at Home – the alternative model of care. Society of Hospital Medicine Greater Philadelphia Chapter 13th Annual Hospitalist Leaders’ Summit. Wynnewood, PA. Truong T. Remote Patient Monitoring: AI-Enhanced Care Beyond Hospital Walls HealthIMPACT Live – Measuring the Impact of AI in Healthcare Half Day Virtual Summit. September, 2025. New York, NY. Truong T. Hospital at Home as a Vessel for Culturally Congruent and Socially Responsible Care. American Academy of Home Care Medicine Annual Meeting. October, 2025. New Orleans, LA. Truong T. Building the Home Care Continuum: Motivating Patients Through Safe, Tech-Enabled Acute Care. HITLAB Innovators Summit 2025. December, 2025. New York, NY.

Mount Sinai Queens Presentations (Abstracts and Workshops) Hospital Medicine Navid K. Transitions in Care: Timing of Discharge Notice. [Poster Abstract]. Society of Hospital Medicine. March, 2026. Nashville, TN.

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Mount Sinai South Nassau Publications Anaekwe A, Brennan K, Glatt AE. ACP Journal Club Editorial Team at McMaster University. In urogenital gonorrhea, gepotidacin was noninferior to ceftriaxone + azithromycin for microbiological success. Ann Intern Med. 2025 Aug;178(8):JC88. doi: 10.7326/ANNALS-2502853-JC. Epub 2025 Aug 5. PMID: 40759023. Huang AA, Huang SY. Enhancing medical education through statistics: Bridging quantitative literacy and sports supplementation research for improved clinical practice. Nutrients. 2025;17(15):2463. Khan H, Slomovich S, Shah N, Gress F. Interventional Endoscopic Ultrasonography: Advances in Application. Clin Med. 2025 May 8;14(10):3286. doi: 10.3390/jcm14103286. Leyfman Y, et al. Empowering Global Hematology-Oncology Education: Assessing the Impact of a Virtual Platform in Combating Educational Inequity. JCO Glob Oncol. 2025 Nov;11:e2500190. doi: 10.1200/GO-25-00190. Epub 2025 Nov 26.

Mount Sinai South Nassau Presentations (Abstracts and Workshops) Rosen A, Vargas R, Kohansieh M, Kordieh A, Kaur S, Ziyadin L, Singh A, Habbsa S, Guo J. Assessing health disparities in hypoglycemic outcomes for insulin pump users: Insights from a retrospective EMR study. [Poster] American Association of Clinical Endocrinology; May, 2025; Orlando, FL.

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