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Accreditation Quality Report
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Quality Report

Summary of Accreditation Quality Information
St. Luke's-Roosevelt Hospital Center
Org ID: 5836
1000 10th Avenue
New York, NY  10019
(212)523-4000
www.wehealny.org

Accreditation
Programs		 Accreditation
Decision		 Effective
Date		 Last Full Survey Date Last On-Site Survey Date  
Behavioral Health Care
Accredited 9/23/2009 9/22/2009 9/22/2009  
Hospital
Accredited 9/26/2009 9/25/2009 9/25/2009  



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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
Behavioral Health Care
2009 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
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 below the target range/value.
This organization’s performance is below the target range/value.
Heart Failure Care See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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.
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Blood Vessel Surgery
 See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below 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 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 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
1090 Amsterdam Avenue
1090 Amsterdam avenue
New York, NY  10029
  • General Outpatient Services (Outpatient)
147 St
2771 Fredrick Dougla Boulevard
New York, NY  10039
  • General Outpatient Services (Outpatient)
241 Central Park West
241 Central Park West
New York, NY  10023
  • Single Specialty Group Practice (Outpatient)
330 West 58 St
330 West 58 St
New York, NY  10029
  • Single Specialty Group Practice (Outpatient)
411 West 114 Street
411 West 114 Street
New York, NY  10025
  • Behavioral Health (Non 24 Hour Care - Adult/Child/Youth)
  • Chemical Dependency (Non 24 Hour Care - Adult/Child/Youth)
50 West 77 Street
50 West 77 Street
New York, NY  10024
  • Multi Specialty Group Practice (Outpatient)
Brodsky
425 West 59 Street
New York, NY  10019
  • Ambulatory Surgery Center (Outpatient)
  • Anesthesia (Outpatient)
  • Multi Specialty Group Practice (Outpatient)
Center for Comprehensive Care
36 Seventh Avenue
New York, NY  10011
  • Single Specialty Group Practice (Outpatient)
Louis D. Brandeis High School
145 West 84th Street
New York, NY  10024
  • General Outpatient Services (Outpatient)
Martin Luther High School
122 Amsterdam Avenue
New York, NY  10025
  • General Outpatient Services (Outpatient)
Phillip Randolph High School
West 135th Street & Convent Avenue
New York, NY  10028
  • General Outpatient Services (Outpatient)
Roosevelt Division  *
1000 10th Avenue
New York, NY  10019
  • Addiction Care (Inpatient, Outpatient)
  • Alcohol & Drug Rehabilitation (Inpatient, Outpatient)
  • Allergy (Outpatient)
  • Audiology (Outpatient)
  • Behavioral Health (Day Programs - Adult)
    (Non 24 Hour Care - Adult)
    (24-hour Acute Care/Crisis Stabilization - Adult)
  • Cancer Center/Oncology (Inpatient, Outpatient)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • Chemical Dependency (Day Programs - Adult)
    (Non 24 Hour Care - Adult)
  • CT Scanner (Inpatient, Outpatient)
  • Dentistry (Inpatient, Outpatient)
  • Dermatology (Inpatient)
  • Developmental Disabilities - Hospital (Outpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Infusion Therapy (Inpatient, Outpatient)
  • Inpatient Intake (Inpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient)
  • Labor & Delivery (Inpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
  • Neonatal Intensive Care (Inpatient)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Neurosurgery (Inpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Nursery (Inpatient)
  • Obstetrics (Inpatient, Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Radiation Oncology (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
St, Luke's Divison
1111 Amsterdam Avenue
New York, NY  10025
  • Addiction Care (Inpatient, Outpatient)
  • Alcohol & Drug Rehabilitation (Inpatient, Outpatient)
  • Audiology (Outpatient)
  • Behavioral Health (Day Programs - Adult)
    (Non 24 Hour Care - Adult/Child/Youth)
    (24-hour Acute Care/Crisis Stabilization - Adult)
  • Cardiac Catheterization Lab (Inpatient, Outpatient)
  • Cardiac Surgery (Inpatient)
  • Cardiac Unit/Cardiology (Inpatient)
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult)
  • CT Scanner (Inpatient, Outpatient)
  • Dementia Care (Inpatient)
  • Dentistry (Outpatient)
  • Dermatology (Outpatient)
  • Dialysis (Inpatient)
  • EEG/EKG/EMG Lab (Inpatient, Outpatient)
  • Electroconvulsive Therapy (Inpatient)
  • Emergency Room (Outpatient)
  • Endocrinology (Inpatient, Outpatient)
  • Gastroenterology (Inpatient, Outpatient)
  • General Medical Services (Inpatient, Outpatient)
  • General Surgery (Inpatient, Outpatient)
  • GI or Endoscopy Lab (Inpatient, Outpatient)
  • Gynecology (Inpatient, Outpatient)
  • Hematology/Blood Treatment (Inpatient, Outpatient)
  • Imaging/Radiology (Inpatient, Outpatient)
  • Infectious Diseases (Inpatient, Outpatient)
  • Intensive Care Unit (Inpatient)
  • Internal Medicine (Inpatient, Outpatient)
  • Magnetic Resonance Imaging (Inpatient, Outpatient)
  • Medical Detoxification (Inpatient)
  • Mental Health (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization)
  • Nephrology (Inpatient, Outpatient)
  • Neurology (Inpatient, Outpatient)
  • Nuclear Medicine (Inpatient, Outpatient)
  • Obstetrics (Outpatient)
  • Operating Room (Inpatient, Outpatient)
  • Ophthalmology/Eye Surgery (Inpatient, Outpatient)
  • Oral Maxillofacial Surgery (Inpatient, Outpatient)
  • Orthopedic Surgery (Inpatient, Outpatient)
  • Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient)
  • Outpatient Surgery (Outpatient)
  • Pain Management (Inpatient)
  • Pediatric Care (Inpatient, Outpatient)
  • Plastic Surgery (Inpatient, Outpatient)
  • Podiatry (Inpatient, Outpatient)
  • Post Anesthesia Care Unit (PACU) (Inpatient, Outpatient)
  • Pulmonary Function Lab (Inpatient, Outpatient)
  • Rehabilitation and Physical Medicine (Inpatient, Outpatient)
  • Respiratory Care (Ventilator) (Inpatient)
  • Rheumatology (Inpatient, Outpatient)
  • Telemetry (Inpatient)
  • Thoracic Surgery (Inpatient)
  • Ultrasound (Inpatient, Outpatient)
  • Urgent Care/Emergency Medicine (Outpatient)
  • Urology (Inpatient, Outpatient)
  • Vascular Surgery (Inpatient, Outpatient)
Trinity House
324 W 108 St
New York, NY  10025
  • Behavioral Health (Non 24 Hour Care - Adult)
  • General Outpatient Services (Outpatient)

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