Quality Report


Quality Report

Staten Island University Hospital
HCO ID: 4979
475 Seaview Ave
Staten Island, NY, 10305
(718) 226-9000
www.siuh.edu
Summary of Quality Information

Accreditation Programs

Gold Seal
Home Care
Accreditation Decision
Effective Date
7/15/2023
Last Full Survey Date
7/14/2023
Last On-Site Survey Date
7/14/2023
Gold Seal
Hospital
Accreditation Decision
Effective Date
7/15/2023
Last Full Survey Date
7/14/2023
Last On-Site Survey Date
7/14/2023

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
2/3/2023
Last Full Survey Date
12/2/2022
Last On-Site Survey Date
12/2/2022
Gold Seal
Certification Decision
Effective Date
7/5/2023
Last Full Survey Date
6/14/2023
Last On-Site Survey Date
6/14/2023
Gold Seal
Certification Decision
Effective Date
10/29/2022
Last Full Survey Date
10/28/2022
Last On-Site Survey Date
10/28/2022
Gold Seal
Certification Decision
Effective Date
10/10/2022
Last Full Survey Date
8/5/2022
Last On-Site Survey Date
8/5/2022

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
5/6/2023
Last Full Survey Date
5/5/2023
Last On-Site Survey Date
5/5/2023

Sites

Anticoagulation
256 C Mason Avenue
Staten Island, NY, 10305

Available Services

  • Single Specialty Practitioner (Outpatient )

Center for Ambulatory Surgery
252 Mason Avenue Staten Island
Staten Island, NY, 10305

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Center for Women's Health
440 Seaview Avenue
Staten Island, NY, 10305

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )

Florina Cancer Center
475 Seaview Ave
Staten Island, NY, 10305

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Hazardous Medication Compounding (Outpatient )
  • Outpatient Clinics (Outpatient )

Medical Arts Pavilion
242 Mason Ave
Staten Island, NY, 10305

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Ophthalmology (Outpatient - Child/Youth )
  • Pediatric Otolaryngology (Outpatient - Child/Youth )
  • Pediatric Urology (Outpatient - Child/Youth )
  • Perform Invasive Procedure (Outpatient )

New Dorp High School
465 New Dorp Lane
Staten Island, NY, 10306

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • School based hospital extension clinic

Port Richmond High School
85 St. Joseph's Avenue
Staten Island, NY, 10302

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • school based extension clinic

Staten Island University Hospital
450 Seaview Avenue
Staten Island, NY, 10305

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Employment Services (Non 24 Hour Care )
  • Family Support (Non 24 Hour Care )
  • Peer Support (Non 24 Hour Care )

Staten Island University Hospital (North)
475 Seaview Avenue
Staten Island, NY, 10305

Available Services

  • Brachytherapy (Imaging/Diagnostic Services )
  • Burn Unit (Inpatient )
  • 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 )
  • Dialysis Unit (Inpatient )
  • 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 )
  • Hazardous Medication Compounding (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 )
  • Neuro/Spine ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sterile Medication Compounding (Inpatient )
  • 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 )

Certification Programs

  • Advanced Comprehensive Stroke Center
  • Advanced Palliative Care
  • Spine Surgery

Staten Island University Hospital (Prince's Bay)
375 Seguine Avenue
Staten Island, NY, 10309

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Community Integration (Non 24 Hour Care )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Family Support (Non 24 Hour Care )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Non-Sterile Medication Compounding (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Outpatient Clinics (Outpatient )
  • Peer Support (Non 24 Hour Care )
  • Plastic Surgery (Surgical Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Certification Programs

  • Advanced Palliative Care
  • Advanced Total Hip and Total Knee Replacement
  • Primary Stroke Center

Staten Island University Hospital - University Hospice
78 Meisner Avenue
Staten Island, NY, 10306

Available Services

  • Hospice Care

Other Clinics/Practices Located at This Site:

  • University Hospice

Staten Island University Hospital Burn Outpatient Clinic
500 Seaview Avenue
Staten Island, NY, 10305

Available Services

  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Verrazzano Imaging at Staten Island University Hospital
256A Mason Avenue
Staten Island, NY, 10305

Available Services

  • Single Specialty Practitioner (Outpatient )

Organization Commentary

Dr. Brahim Ardolic, Executive Director

Amended Version from 6/1/09 Staten Island University Hospital is a Joint Commission Codman Award Winner in the Hospital category and the Consumer Choice Award Hospital of Staten Island. SIUH is a member of the North Shore Long Island Jewish Health System. We are a tertiary care, teaching hospital with two in-patient locations with over 700 beds. SIUH provides a full spectrum of healthcare throughout the continuum. We offer a Level (one) 1 trauma service, cardiac surgery, regional perinatal care, ambulatory cancer services, state of the art digital mammography and radiology services, interventional cardiology, regional burn unit and fellowiship trained physicians and surgeons in all major areas. We offer a Bariatric Surgery Program recognized as a "Center of Excellence" by the American Society of Bariatric Surgery, offering nutrional, psychological and support groups from pre-surgical management to life-time after care. A comprehensive Psychiatry and Behavioral Sciences Program including inpatient and outpatient services as well as a full spectrum of substance abuse, including detox and rehabilitation services. In addition special recognition has been acheived by the following services: SIUH has been recognized as a top performer across the Center for Medicare and Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstration Project's six years, based on its overall quality scores. SIUH is one of two hospitals to recieve 39 awards, the highest number of awards recieved among all participants. Through the project, hospitals submitted a set of more than 30 evidence-based clinical quality meassures across six hiigh volume clinical areas - acute myocardial infarction, heart failure, coronary artery bypass graft, pneumonia, hip and knee replacement, and the surgical care improvement project. For outstanding perforance in measuring and improving the quality of care, SIUH recieved the prestigious National 2006 Premier Award for Quality in the area of Maternal and Neonatal Care for the lowest C-Section rate nationally and one of the highest success rates for Vbacks. Only a select number of hospitals in the United States have recieved this award. SIUH was designated as a "Stroke Center" by the New York State Deprtment of Health in 2005. The designation represents a organization-wide committment to national standards for comprehensive stroke care. In 2011, SIUH recieved the "Get With The Guidelines" Stroke Gold Plus Performance Achievement Award from the American Heart Association and the American Stroke Association for the third consecutive year. In 2004, SIUH was awarded JCAHO's Codman Award for Performance Improvement. This achievement is awarded to organizations who achieve excellence in healthcare quality improvement through the use of performance data. In 2003 and again in 2008, SIUH was awarded the Hospital Association of New York State (HANYS) Pinnacle Award for Quality Improvement. The project for 2008 was focused on improving quality of care in cultural transformation to prevent falls and associated injuries in a tertiary care hospital. In February 2008, SIUH's Department of Rehabilitation Medicine's Inpatient and Outpatient rehabilitation programs were awarded a three (3) year accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF). The Department was recognized as being one of the top 3% of facilities nationwide that successfully completed a survey without any recommendations. SIUH was recognized in April of 2008, by both the New York Organ Donor Network and the Department of Health and Human Resources (HHS) as having a 100% referral rate for organ donors and a higher than standard actual donation rate. In June 2011, the American College of Surgeons Commission on Cancer recognized SIUH with a three year approval of our Teaching Hospital Cancer Program.

Cooperative Agreements

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures 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.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures 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.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2020 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.