The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Maimonides Medical Center
Org ID: 5734
4802 Tenth Avenue
Brooklyn, NY  11219-2916
(718)283-6000
www.maimonidesmed.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 2/11/2012 1/16/2009   10/25/2012  
Hospital
Accredited 2/11/2012 2/10/2012   2/19/2014  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 5/1/2013  4/30/2013  4/30/2013 
Ventricular Assist Device
Certification 8/24/2012  8/23/2012  8/23/2012 





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  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
This measure is not applicable for this organization.
Not displayed
  Footnote Key
1. The measure or measure set was not reported.
2. The measure set does not have an overall result.
3. The number is not enough for comparison purposes.
4. The measure meets the Privacy Disclosure Threshold rule.
5. The organization scored above 90% but was below most other organizations.
6. The measure results are not statistically valid.
7. The measure results are based on a sample of patients.
8. The number of months with measure data is below the reporting requirement.
9. The measure results are temporarily suppressed pending resubmission of updated data.
10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Behavioral Health Care
2012 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Hospital
2013 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Jul  2012 -
Jun  2013
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Pneumonia Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Blood Vessel Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Colon/Large Intestine Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Coronary Artery Bypass Graft
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hip Joint Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Knee Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Open Heart Surgery
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
 
 
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
57th Street Adult Primary Care Center
1250 57th Street
Brooklyn, NY  11219
    Services:
    • Outpatient Clinics (Outpatient)
    Adult Outpatient Services Developmental Division
    947-49th Street
    Brooklyn, NY  11219
      Services:
      • Behavioral Health (Non 24 Hour Care - Adult)
      Ambulatory Health Services
      948 48th Street
      Brooklyn, NY  11219
        Services:
        • Outpatient Clinics (Outpatient)
        Ambulatory Surgery & Endoscopy Center
        1025 48th Street
        Brooklyn, NY  11219
          Services:
          • Administration of Blood Product (Outpatient)
          • Administration of High Risk Medications (Outpatient)
          • Ambulatory Surgery Center (Outpatient)
          • Anesthesia (Outpatient)
          • Perform Invasive Procedure (Outpatient)
          Bay Parkway Multi Specialty Pediatric Center
          6701 Bay Parkway
          Brooklyn, NY  11204
            Services:
            • Outpatient Clinics (Outpatient)
            Cancer Center of Brooklyn (Breast Program)
            745 64th Street
            Brooklyn, NY  11220
              Services:
              • Outpatient Clinics (Outpatient)
              • Perform Invasive Procedure (Outpatient)
              Cancer Center of Brooklyn (Rad Onc/Hem Onc)
              6300 8th Avenue
              Brooklyn, NY  11220
                Services:
                • Administration of Blood Product (Outpatient)
                • Administration of High Risk Medications (Outpatient)
                • Outpatient Clinics (Outpatient)
                • Perform Invasive Procedure (Outpatient)
                Cardiology Outpatient
                848 49th Street
                Brooklyn, NY  11220
                  Services:
                  • Single Specialty Practitioner (Outpatient)
                  Cardiology Outpatient
                  421 Ocean Parkway
                  Brooklyn, NY  11218
                    Services:
                    • Single Specialty Practitioner (Outpatient)
                    Community Mental Health Center
                    920 48th Street
                    Brooklyn, NY  11219
                      Services:
                      • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)
                        (24-hour Acute Care/Crisis Stabilization - Adult)
                      Maimonides Bone & Joint Center
                      6010 Bay Parkway
                      Brooklyn, NY  11204
                        Services:
                        • Single Specialty Practitioner (Outpatient)
                        Maimonides Medical Center  *
                        4802 Tenth Avenue
                        Brooklyn, NY  11219
                        Joint Commission Advanced Certification Programs:
                        • Primary Stroke Center
                        • Ventricular Assist Device
                          Services:
                          • Cardiac Catheterization Lab (Surgical Services)
                          • Cardiac Surgery (Surgical Services)
                          • Cardiothoracic Surgery (Surgical Services)
                          • Cardiovascular Unit (Inpatient)
                          • Coronary Care Unit (Inpatient)
                          • CT Scanner (Imaging/Diagnostic Services)
                          • Ear/Nose/Throat Surgery (Surgical Services)
                          • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                          • Gastroenterology (Surgical Services)
                          • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                          • Gynecological Surgery (Surgical Services)
                          • Gynecology (Inpatient)
                          • Hematology/Oncology Unit (Inpatient)
                          • Interventional Radiology (Imaging/Diagnostic Services)
                          • Labor & Delivery (Inpatient)
                          • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                          • Medical /Surgical Unit (Inpatient)
                          • Medical ICU (Intensive Care Unit)
                          • Neurosurgery (Surgical Services)
                          • Normal Newborn Nursery (Inpatient)
                          • Nuclear Medicine (Imaging/Diagnostic Services)
                          • Orthopedic Surgery (Surgical Services)
                          • Orthopedic/Spine Unit (Inpatient)
                          • Pediatric Unit (Inpatient)
                          • Plastic Surgery (Surgical Services)
                          • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                          • Post Anesthesia Care Unit (PACU) (Inpatient)
                          • Radiation Oncology (Imaging/Diagnostic Services)
                          • Sleep Laboratory (Sleep Laboratory)
                          • Surgical ICU (Intensive Care Unit)
                          • Surgical Unit (Inpatient)
                          • Teleradiology (Imaging/Diagnostic Services)
                          • Thoracic Surgery (Surgical Services)
                          • Ultrasound (Imaging/Diagnostic Services)
                          • Urology (Surgical Services)
                          • Vascular Surgery (Surgical Services)
                          Maimonides Outpatient Rehabilitation Center
                          883 65th Street
                          Brooklyn, NY  11220
                            Services:
                            • Outpatient Clinics (Outpatient)
                            MMC Reproductive Endocrinology
                            1355 84th Street
                            Brooklyn, NY  11228
                              Services:
                              • Anesthesia (Outpatient)
                              • Perform Invasive Procedure (Outpatient)
                              • Single Specialty Practitioner (Outpatient)
                              MMC Sleep Lab
                              6405 7th Avenue - 3rd Floor
                              Brooklyn, NY  11220
                                Services:
                                • Single Specialty Practitioner (Outpatient)
                                Newkirk Family Health Center
                                1401 Newkirk Avenue
                                Brooklyn, NY  11230
                                  Services:
                                  • Outpatient Clinics (Outpatient)
                                  Ob/Gyn Women's Pavilion
                                  6208 Fourth Avenue
                                  Brooklyn, NY  11220
                                    Services:
                                    • Anesthesia (Outpatient)
                                    • Perform Invasive Procedure (Outpatient)
                                    • Single Specialty Practitioner (Outpatient)
                                    Pediatric Dentistry
                                    4305 13th Avenue
                                    Brooklyn, NY  11219
                                      Services:
                                      • Single Specialty Practitioner (Outpatient)
                                      Pediatric Primary Care Center
                                      1301 57th Street
                                      Brooklyn, NY  11219
                                        Services:
                                        • Single Specialty Practitioner (Outpatient)
                                        Perinatal Testing Center
                                        5014 Fort Hamilton Parkway
                                        Brooklyn, NY  11219
                                          Services:
                                          • Outpatient Clinics (Outpatient)
                                          Pre Admission Testing
                                          745 64th Street
                                          Brooklyn, NY  11220
                                            Services:
                                            • Single Specialty Practitioner (Outpatient)
                                            Primary Health Center
                                            6323 Seventh Avenue
                                            Brooklyn, NY  11220
                                              Services:
                                              • Outpatient Clinics (Outpatient)
                                              South Beach Bensonhurst Clinic
                                              8620 18th Avenue
                                              Brooklyn, NY  11214
                                                Services:
                                                • Single Specialty Practitioner (Outpatient)
                                                South Beach Fort Hamiton Clinic
                                                8710 5th Avenue
                                                Brooklyn, NY  11209
                                                  Services:
                                                  • Single Specialty Practitioner (Outpatient)
                                                  South Beach Mapleton Clinic
                                                  1083 McDonald Avenue
                                                  Brooklyn, NY  11230
                                                    Services:
                                                    • Single Specialty Practitioner (Outpatient)
                                                    Women's Primary Care Services
                                                    4422 Ninth Avenue
                                                    Brooklyn, NY  11220
                                                      Services:
                                                      • Outpatient Clinics (Outpatient)

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