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Accreditation Quality Report
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Quality Report

Summary of Accreditation Quality Information
SUNY Downstate Medical Center University Hosp. of Brooklyn
Org ID: 5737
445 Lenox Road, Box 23
Brooklyn, NY  11203
(718)270-1000
www.downstate.edu

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Hospital
Accredited 4/19/2008 4/18/2008 11/20/2009  



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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 of patients 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.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Hospital
2010 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:
Jan  2009 -
Dec  2009
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 below the target range/value.
This organization’s performance is below the target range/value.
Pregnancy Care See Detail
Not displayed.
2
Not displayed.
2
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
 See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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 similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hip Joint Replacement
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hysterectomy
 See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below the target range/value.
  • Knee Replacement
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Open Heart 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.
SCIP – Venous Thromboembolism (VTE) See Detail
   
  30 Day Risk Adjusted Mortality Rates (see details)
  30 Day Hospital Readmission Rates (see details)
  Survey of Patients' Hospital Experiences (see details)
 
Hospitals voluntarily participate in the Survey of Patients' Hospital Experiences(HCAHPS).
Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population.
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
Center for Health Services - Bedford Stuyvesant
613 Throop Avenue
Brooklyn, NY  11216
  • General Outpatient Services (Outpatient)
Center For Health Services - Midwood
2171 Nostrand Avenue
Brooklyn, NY  11210
  • General Outpatient Services (Outpatient)
PS 13
567 Pennsylvania Avenue
Brooklyn, NY  11207
  • General Outpatient Services (Outpatient)
State University of New York/University Hospital of Brooklyn  *
445 Lenox Road
Brooklyn, NY  11203
  • Acute Myocardial Infarction (Inpatient)
  • Alzheimers Disease (Inpatient)
  • Arthritis (Outpatient)
  • Asthma (Inpatient, Outpatient)
  • Asthma, Pediatrics (Inpatient, Outpatient)
  • Atrial Fibrillation (Inpatient, Outpatient)
  • Attention Deficit Disorder (Outpatient)
  • Audiology (Inpatient, Outpatient)
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
  • Benign prostatic hyperplasia (BPH) (Inpatient, Outpatient)
  • Bipolar disorder (Inpatient, Outpatient)
  • Breast Cancer (Inpatient, Outpatient)
  • Cancer Center/Oncology (Inpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient, Outpatient)
  • Carotid Stenosis (Inpatient, Outpatient)
  • Cervical Spine Treatment (Inpatient, Outpatient)
  • Chronic Kidney Disease (Inpatient, Outpatient)
  • Coagulopathy Treatment (Inpatient, Outpatient)
  • Colon/Rectal Cancer (Inpatient, Outpatient)
  • Coronary Artery Bypass Graft (Inpatient)
  • Coronary Artery Disease (Inpatient, Outpatient)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Outpatient)
  • Depression (Inpatient, Outpatient)
  • Dermatology (Outpatient)
  • Developmental Disabilities - Hospital (Outpatient)
  • Diabetes Mellitus (Inpatient, Outpatient)
  • Dialysis (Inpatient, Outpatient)
  • EEG/EKG/EMG Lab (Inpatient)
  • Emergency Room (Outpatient)
  • End Stage Renal Disease (Inpatient, Outpatient)
  • Endocrinology (Outpatient)
  • Epilepsy (Inpatient, Outpatient)
  • Family Practice (Inpatient, Outpatient)
  • Gastroenterology (Outpatient)
  • Gastroesophageal Reflux Disease (Inpatient, Outpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient)
  • Genetic Testing / Counseling (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Head Injury (Inpatient)
  • Health and Wellness (Inpatient, Outpatient)
  • Heart Failure (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient)
  • Hepatitis B/C (Inpatient, Outpatient)
  • High Risk Neonatal (Inpatient)
  • High Risk Obstetrics (Inpatient)
  • Hip Joint Replacement (Inpatient, Outpatient)
  • HIV Clinic (Outpatient)
  • HIV/AIDS (Inpatient, Outpatient)
  • Hodgkin's disease (Inpatient, Outpatient)
  • Hyperbilirubinemia (Inpatient, Outpatient)
  • Hyperlipidemia (Inpatient, Outpatient)
  • Hypertension (Inpatient, Outpatient)
  • Hyperthyroidism/Hypothyroidism (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient)
  • Infertility (Inpatient, Outpatient)
  • Infusion Therapy (Outpatient)
  • Inpatient Diabetes (Inpatient)
  • Inpatient Intake (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Interventional Cardiac Catheterization (Inpatient, Outpatient)
  • Interventional Radiology (Inpatient, Outpatient)
  • Intraventricular hemorrhage (Inpatient)
  • Irritable Bowel Syndrome (Inpatient, Outpatient)
  • Ischemic Heart Disease (Inpatient, Outpatient)
  • Joint Replacement - Ankle (Inpatient)
  • Joint Replacement - Knee (Inpatient)
  • Labor & Delivery (Inpatient)
  • Laminectomy (Inpatient)
  • Leukemia (Inpatient, Outpatient)
  • Liver Diseases (Inpatient)
  • Lumbar Spine Treatment (Inpatient, Outpatient)
  • Lung Cancer (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Maternal Child (Inpatient, Outpatient)
  • Mental Health (Inpatient, 24-hour Acute Care/Crisis Stabilization)
  • Morbid Obesity (Outpatient)
  • Necrotizing Enteral Colitis (Inpatient, Outpatient)
  • Neonatal Intensive Care (Inpatient)
  • Neonatology (Inpatient, Outpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Nutrition Programs (Outpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Occupational Health (Outpatient)
  • Operating Room (Inpatient)
  • Organ Transplant - Kidney (Inpatient)
  • Organ Transplant - Kidney/Pancreas (Inpatient)
  • Organ Transplant - Lung (Inpatient)
  • Orthopedic Surgery (Inpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient)
  • Outpatient Surgery (Outpatient)
  • Pancreatic Cancer (Inpatient, Outpatient)
  • Pancreatitis (Inpatient, Outpatient)
  • Pathology (Inpatient, Outpatient)
  • Pediatric Allergy/Immunology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Cardiology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Care (Inpatient, Outpatient)
  • Pediatric Dentistry (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Dermatology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Emergency Department (Outpatient - Child/Youth)
  • Pediatric Emergency Medicine (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Endocrinology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Gastroenterology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric General Surgery (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Hematology/Oncology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Intensivists (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Nephrology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Neurology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Ophthalmology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Orthopedics (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Otolaryngology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Pathology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Physical Medicine and Rehab (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Plastic Surgery (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Pulmonology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Radiology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pediatric Urology (Inpatient - Child/Youth)
    (Outpatient - Child/Youth)
  • Pelvic Inflammatory Disease (Inpatient, Outpatient)
  • Perimenopause (Inpatient, Outpatient)
  • Peripheral Vascular Disease (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient)
  • Pneumonia (Inpatient, Outpatient)
  • Podiatry (Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient)
  • Prematurity (Inpatient, Outpatient)
  • Prostate Cancer (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient)
  • Radiation Oncology (Inpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Respiratory Failure (Inpatient, Outpatient)
  • Schizophrenia (Inpatient, Outpatient)
  • Sexually Transmitted Disease (Inpatient, Outpatient)
  • Sickle Cell Disease (Inpatient, Outpatient)
  • Sleep Center (Outpatient)
  • Sleeping Disorder (Inpatient, Outpatient)
  • Solid Organ Transplant (Inpatient)
  • Spine Care (Inpatient, Outpatient)
  • Sports Medicine (Inpatient)
  • Stroke Rehabilitation (Inpatient, Outpatient)
  • Stroke (Primary Stroke Center) (Inpatient, Outpatient)
  • Systemic Lupus Erythematosis (Inpatient, Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Spine (Inpatient, Outpatient)
  • Thoracic Surgery (Inpatient)
  • Tobacco Treatment / Cessation (Inpatient, Outpatient)
  • Trauma (Outpatient)
  • Tuberculosis (Inpatient, Outpatient)
  • Ulcerative Colitis (Inpatient, Outpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient)
  • Vascular Disease (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient)
  • Weight Loss (Outpatient)
  • Women's Health (Inpatient, Outpatient)
SUNY - Parkside Dialysis Center
710 Parkside Avenue
Brooklyn, NY  11203
  • General Outpatient Services (Outpatient)
SUNY Bay Ridge Center
166 Battery Avenue
Brooklyn, NY  11228
  • Ambulatory Surgery Center (Outpatient)
  • Anesthesia (Outpatient)
SUNY Downstate Medical Center at Bayridge
699 92nd Street
Brooklyn, NY  11228
  • Ambulatory Surgery Center (Outpatient)
  • Anesthesia (Outpatient)
  • Convenient Care Center (Outpatient)
  • General Outpatient Services (Outpatient)
University Hospital of Brooklyn Family Health Service
840 Lefferts Avenue
Brooklyn, NY  11203
  • General Outpatient Services (Outpatient)
Wingate High School
600 Kingston Avenue
Brooklyn, NY  11203
  • General Outpatient Services (Outpatient)

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