How Mount Sinai Developed a Comprehensive Professional Accountability Program

During the early days of the pandemic, Mount Sinai Health System (MSHS) began implementing a comprehensive professional accountability program with support from Vanderbilt Health’s Center for Patient and Professional Advocacy (CPPA).

MSHS is an academic medical center in New York City that includes the Icahn School of Medicine at Mount Sinai, seven teaching hospitals, approximately 9,000 primary and specialty care physicians, about 2,000 advanced practice providers, more than 400 ambulatory practices, and 48,000 employees.

Nashville-based CPPA’s programs use the observations and experiences of patients, families and fellow medical team members to create local and national data and discipline-specific benchmarks to identify, address and support the small group of clinicians who model disrespect towards patients, colleagues and trainees.  

Mount Sinai partnered with CPPA to address unprofessional behavior across its workforce, and the health system says it has since produced measurable results in organizational culture improvement. 

A key achievement of the partnership is MSHS’s 94% share rate for addressing reported unprofessional behavior incidents — among the highest of any CPPA partner site. This means that virtually every submitted report receives appropriate follow-up and intervention. 

The program encompasses all levels of the organization, including medical students, residents and graduate students. Unlike typical approaches that involve leadership in feedback conversations with trainees, MSHS implemented a peer messenger model across all groups.

This approach inspired a research study published in JAMA Network Open, which confirmed the program’s effectiveness in identifying problematic behaviors and fostering a safer learning environment. 

CPPA supported MSHS in consolidating multiple reporting systems into a single database, providing comprehensive visibility into professionalism issues across the health system. The integration captures both formal complaints and informal reports that previously went undocumented, including in-the-moment conversations, emails and phone calls.  

“Shortly after formally launching the program, we received several complaints that required immediate responses,” said Rebecca Anderson, M.P.H., vice president in the Office of the Chief Medical Officer at MSHS, in a statement. “We were prepared and equipped to deal with these situations because of our work with CPPA. We were organized; we had a script; we knew who to bring to the table; and we knew how to properly manage each situation in a structured manner. Being able to effectively navigate these scenarios with tools like our huddles was a clear sign to senior leaders that this program provided a valuable structure and immediate value.” 

The partnership extends beyond basic reporting systems. CPPA has provided strategic consultation on event reporting system transitions, patient relations department optimization and development of professionalism dashboards for department chairs. The collaboration has also included facilitating conversations with the health system’s malpractice insurer. 

MSHS addresses serious professionalism concerns through structured event huddles for reviewing reports requiring additional investigation, such as sexual boundary violations, violence or discrimination. The health system has shared this approach through presentations at national meetings and co-authored publications in BMJ Leader. 

“Mount Sinai Health System’s success is a testament to what’s possible when leadership commits to professional accountability. Their 94% response rate represents a system where concerns are heard; professionalism is protected; and every report is treated as an opportunity to reinforce shared values and improve care,” said Allison Suttle, M.D., M.B.A., executive faculty at CPPA, in a statement.

CPPA said the success stems from MSHS’s commitment to maintaining program fidelity while remaining receptive to feedback and continuous improvement. The organization has sustained momentum through ongoing staff education and consistent messaging about professionalism’s role in organizational culture and values.