Quality and Safety

Patient Care and Experience

Columbia University Irving Medical Center (CUIMC) is dedicated to providing safe, high-quality healthcare while creating an overall superb experience for the patients and families we serve. Under the direction of the Quality, Safety & Patient Experience Committee, we are innovating and expanding our already dynamic structure of practices, policies, and initiatives, from enhanced medical chaperone training to improved patient education and empowerment.

Clinical Care and Safety

From preventing infections to managing medications, CUIMC’s efforts to ensure safe, high-quality care span all departments and practices, and include the following areas of focus:

  • Chaperone training: Our medical chaperone policies promote patient safety, dignity, and comfort during exams, treatments, and procedures and are in complete alignment with our health system partner, NewYork-Presbyterian Hospital. For certain procedures (such as female vaginal and pelvic exams), chaperones are required, while for other procedures, CUIMC providers are required to offer a chaperone to be present. In addition, a patient can request a chaperone during any visit at any time. Chaperone training includes protecting patient well-being, ensuring privacy and confidentiality, verifying the content of clinical conversations and physical exams, and immediately reporting and escalating any concerns.
  • Infection prevention and control: In collaboration with NewYork-Presbyterian, CUIMC upholds evidence-based practices to protect patients and healthcare personnel from infection. These policies and procedures include preventing healthcare-associated infections; minimizing occupational exposures; managing any emerging infections; and educating patients, staff, and visitors about infection prevention and control measures.
  • Medication administration: Our Medication Administration Policy has established consistent processes for clinical staff regarding medication orders (including reconciliation), preparation, administration, documentation, and monitoring. In addition, together with Weill Cornell Medicine and NewYork-Presbyterian, CUIMC has undertaken the Ambulatory Opioid Management Initiative (AOMI), which standardized the adoption of best practices related to prescribing policies, patient and provider education, electronic health record optimization, and shared decision-making between patients and providers.
  • Patient education and empowerment: As part of our efforts to strengthen our partnership with patients, we clearly display “What to expect” documents in exam rooms. With the help of QR codes, these displays specifically explain sensitive procedures so patients fully understand what their visit and treatment will involve. In addition, we have implemented improved signage and outreach to promote anonymous reporting by patients or family members of any concerns regarding the care they receive.
  • Rights and responsibilities of the individual: We confirm our commitment to all points set forth in the New York State Hospital’s Patient Bill of Rights, from ensuring privacy and confidentiality to providing “considerate and respectful care in a clean and safe environment.”
  • Provision of care, treatment, and services: In accordance with The Joint Commission, we uphold the performance requirements related to Provision of Care, Treatment, and Services, which were designed to improve the quality and safety of care provided to pregnant and postpartum women.

More specifically, CUIMC’s quality and safety efforts include a range of distinct projects and initiatives, including:

  • Patient Safety Champion Program: Our Safety Champions are multidisciplinary, frontline providers and employees who are trained to serve as the “face” and “voice” of patient safety within their department. Champions help other staff feel more comfortable about sharing information and asking questions pertaining to safety.
  • Ambulatory Safety Project: Our MCIC Ambulatory Patient Safety Project for 2022-23 focused on infrastructure to support our Journey to High Reliability. As a “highly reliable organization,” CUIMC achieved a score of 95 percent.
  • Enterprise-Wide Ambulatory Quality Committee: This body addresses any quality and patient safety issues across CUIMC, NewYork-Presbyterian, and Weill Cornell Medicine on a monthly basis.
  • Coaching Tracers: Using the Survey Analysis for Evaluating Risk™ (SAFER) matrix, ColumbiaDoctors adopted proactive coaching tracer activities in our ambulatory care sites to promote outstanding practices consistent with current regulations and professional standards.
  • Performance Improvement Program: Using a performance improvement model, this program seeks to achieve greater efficiency, increased throughput, and improved outcomes in care delivery.
  • Regulatory Compliance Program: This program supports ambulatory practices towards continuous compliance with all relevant requirements from federal regulatory agencies and accrediting organizations.

Patient Experience

From the coordination of appointments to the respect shown by providers, the CUIMC community makes sure each patient receives health services in an environment of professionalism, trust, cleanliness, and convenience. In the Department of Obstetrics and Gynecology, we have a patient experience coordinator who is responsible for monitoring quality reviews, documenting any areas for improvement, and following up with patients, providers, and staff.

We are also constantly seeking feedback by asking our patients throughout CUIMC about their experiences through a set of patient experience surveys. Based on 1.7 million visits throughout FY23, we were pleased to hear the following feedback from patients:

  • 94 percent responded “Yes, Definitely” when asked if they would recommend their provider’s office.
  • 91.7 percent gave their doctor an overall MD rating of 9 or 10 on a scale of 1-10.
  • 92.5 percent responded “Yes, Definitely” to questions regarding satisfaction with office staff.
  • 95 percent responded “Yes, Definitely” when asked if they were pleased with the communication they received from their provider, including giving clear explanations, listening to patients, and respecting what patients had to say.
  • Specific to virtual services, 96.8% rated their likelihood of recommending their provider as “Good” or “Very Good.”