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The Exec: Cultural Transformation Key Element of Improving CMS Stars Ranking

Analysis  |  By Christopher Cheney  
   June 28, 2023

NewYork-Presbyterian Queens improved from a 1-star Centers for Medicare & Medicaid Services rank to 5 stars.

To improve the hospital's CMS stars ranking, NewYork-Presbyterian Queens set a clear vision and the goal of wanting to be a regional center of excellence, says Chief Medical Officer Amir Jaffer, MD, MBA.

Jaffer has been CMO of NewYork-Presbyterian Queens since January 2017. He previously served as associate CMO of Rush University Medical Center in Chicago.

HealthLeaders recently talked with Jaffer about a range of issues, including how NewYork-Presbyterian Queens coped with a COVID-19 patient surge in 2020, service line development, and care coordination. The following transcript of that conversation has been lightly edited for clarity and brevity.

HealthLeaders: What are the primary challenges of serving as CMO of NewYork-Presbyterian Queens?

Amir Jaffer: NewYork-Presbyterian Queens is a 535-bed, Level 1 trauma center and tertiary care teaching hospital, part of the NewYork-Presbyterian Hospital enterprise. We are anchored by two Ivy league medical schools, Columbia University Vagelos College of Physicians and Surgeons and Weill Cornell. NewYork-Presbyterian Queens is a primary affiliate of Weill Cornell Medical College. As the chief medical officer at NewYork-Presbyterian Queens, I view any of the challenges that come our way as opportunities to better serve the Queens community of 2.5 million people. Since I joined NewYork-Presbyterian Queens in January 2017, I have identified three big opportunities.

First, the Queens community is extremely diverse, with approximately 48% of the community born abroad. Queens represents more than 120 countries and more than 35 languages. The diverse community we serve, along with our diverse staff, continues to be our biggest strength. Almost half of our employees reside in Queens. We are working every day to understand the needs of the people in Queens we serve, and we offer robust translation and transcription services to ensure we're able to best communicate with our patients.

Second, we are part of the world-class NewYork-Presbyterian Hospital system and have exceptional physicians from Weill Cornell Medicine. Our model allows us to deliver the best care and continue building new programs that serve the needs of the community, right here in Queens. Most notably, we are proud of the new neuro-ICU opening in July; our comprehensive cardiovascular program, which is ranked 3-three stars—the highest for Society of Thoracic Society rating for coronary artery bypass graft surgery; we are ranked five stars by the Centers of Medicaid & Medicare Services; and we are a top 250-ranked hospital by Healthgrades. None of these outcomes would be possible without NewYork-Presbyterian Queens doctors, nurses, and multidisciplinary teams working together.

Third, our team is flexible. During the COVID-19 pandemic, NewYork-Presbyterian Queens was one of the epicenters, and we were at the front lines in taking care of thousands of patients with COVID. Our camaraderie and teamwork made us resilient, allowing us to serve the community.

HL: New York City was one of the early hotspots in the coronavirus pandemic. How did NewYork-Presbyterian Queens handle high patient volumes during the 2020 surge?

Jaffer: During the 2020 COVID-19 surge, NewYork-Presbyterian Queens was an early hotspot. I personally fell ill with COVID-19 on March 13, 2020, and am so grateful for our incredible leadership team, specifically our chair of surgery, Dr. Pierre Saldinger, and chair of medicine, Dr. Joe Cooke, who stepped in to serve the hospital and greater community in unprecedented times. During those first critical weeks, the leadership team helped to determine how we could create capacity, specifically more ICU beds, and work with the larger enterprise as we handled supply chain issues such as managing personal protective equipment.

When I was able to return to work in April 2020, I helped to support our frontline teams, rounding on patients, and logistically working with partners such as Hospital for Special Surgery that assisted in receiving our recovering COVID patients to other facilities, which allowed us to increase our capacity and manage the acutely ill COVID-19 patients.

One of the things I so vividly remember during those early weeks was our team setting up call centers to ensure patients were able to speak to their loved ones because our visitation policy had restricted visitors.

NewYork-Presbyterian Queens Chief Medical Officer Amir Jaffer, MD, MBA. Photo courtesy of NewYork-Presbyterian.

HL: You have helped grow healthcare service lines at NewYork-Presbyterian Queens. What are the keys to success in managing service lines?

Jaffer: I have been fortunate in my time at NewYork-Presbyterian Queens to work very closely with our operational leaders to strategically grow our service lines including orthopedics, cardiovascular, neurosciences, pediatrics, women, cancer, digestive diseases, and primary care. I attribute our success to working collaboratively with our medical group to recruit world-class physicians and build clinical programs with amazing outcomes. In many cases, these programs require multiple disciplines to collaborate, along with equipment and technology that require capital investments. Each year, we build strategic plans with tactical and actionable interventions that have allowed increased market share in a very competitive landscape.

HL: You helped lead the transformation of NewYork-Presbyterian Queens from a 1-star Centers for Medicare & Medicaid Services (CMS) rank to 5 stars. What were the main elements of this transformation?

I am proud to be working with our president, Jaclyn Mucaria, on a team that supported the transformation of NewYork-Presbyterian Queens to become a CMS 5-star ranked hospital. This happened in part due to a cultural transformation where we set a clear vision and the goal of wanting to be a regional center of excellence and to be the first choice for patients, employees, and physicians.

As part of this work, we committed to putting patients first and outlining our values (respect, empathy, teamwork, innovation, and responsibility) that helped lay a strong foundation for our high reliability framework of tiered huddles and helped create a safety culture, which created psychological safety and the ability for people to speak up with leaders. Working in tandem with our care team and leadership team, we created transparency through scorecards and dashboards, and we held our leaders accountable across the board, which helped increase our scores over five years.

HL: What are the keys to success in care coordination?

Jaffer: In my experience, the key to success in care coordination is a 360-degree approach where we are constantly evaluating every individual at every portion of their wellness journey. If it has been determined that an individual's health is declining in the outpatient setting, we should work with them and ensure we can have the best possible team managing their care. Similarly in the inpatient setting, I believe we should be working with the full care team to develop a plan to bring patients back to their baseline health status—putting the patient's safety and ultimate transition back to a pre-illness state or improved as the end goal.

Good communication is paramount, including our doctors, nurses, case management, social workers, navigators, and care coordinators.

We are proud of our robust care coordination services that allow us to be successful and have low readmission rates, along with our navigator program that aids patients in being guided to additional services post-hospital stay.

HL: Your hospital serves a diverse patient population. What is the hospital doing to promote health equity?

Jaffer: NewYork-Presbyterian Queens is proud of the diverse patient population we serve. NYP launched the Dalio Center for Health Justice in 2020 with the aim of understanding and addressing the root causes of health inequities, and with the goal of setting a new standard of health for the communities we serve.

HL: You have a clinical background in internal medicine. How has this clinical background helped prepare you to serve in administrative roles such as CMO?

Jaffer: When I started my career, I thought I would eventually want to be a gastroenterologist but found that as a generalist, I had more opportunities to teach students and residents, which was my passion early in my career. I began taking on more responsibility in building innovative programming, and my generalist background allowed me to have a 360-degree view in working with different types of patients such as surgical, medical, inpatient, and outpatient. As an expert in hospital and perioperative medicine, I had the opportunity to work collaboratively with different specialties that allowed me to see the large spectrum of diseases.

Through my career and as a CMO working with every specialty and a variety of physicians across different specialties, I have gained a deeper understanding of the various disciplines. I am never shy to ask whether I can come and observe and round in their area. As a leader, this understanding helps me to address challenges they are experiencing and better understand how to help physicians and solve problems.

Related: The Exec: Mass General Brigham CMO Focused on Patient Capacity

Christopher Cheney is the CMO editor at HealthLeaders.


At NewYork-Presbyterian Queens, service line development success has included working collaboratively with the medical group to recruit world-class physicians and building clinical programs with good outcomes.

At the hospital, improving the facility's CMS stars ranking has included laying a strong foundation for a high-reliability framework of tiered huddles and creating a safety culture.

To achieve success in care coordination, good communication is paramount, including doctors, nurses, case management, social workers, navigators, and care coordinators.

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