The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Maimonides Medical Center
DBA: 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
Hospital
Accredited 1/17/2015 1/16/2015   2/25/2015  


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  4/14/2015  4/14/2015 
Ventricular Assist Device
Certification 7/30/2014  7/29/2014  7/29/2014 




Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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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.
11. There were no eligible patients that met the denominator criteria.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Hospital
2015 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:
Oct  2013 -
Sep  2014
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.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
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.
Stroke Care See Detail
Not displayed.
8
Not displayed.
8
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 above the target range/value.
This organization’s performance is above the target range/value.
  • Colon/Large Intestine Surgery
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above 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 above the target range/value.
This organization’s performance is above 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
Ambulatory Services OPD
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)
      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:
            • Outpatient Clinics (Outpatient)
            Cardiology Outpatient
            421 Ocean Parkway
            Brooklyn, NY  11218
              Services:
              • Outpatient Clinics (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 Adult Primary Care Center
                1250 57th Street
                Brooklyn, NY  11219
                  Services:
                  • Outpatient Clinics (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)
                    • Inpatient 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 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)
                          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)
                              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)
                                  Women's Primary Care Services
                                  4422 Ninth Avenue
                                  Brooklyn, NY  11220
                                    Services:
                                    • Outpatient Clinics (Outpatient)

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