Quality Report


Quality Report

Maimonides Medical Center

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

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
2/10/2024
Last Full Survey Date
7/16/2021
Last On-Site Survey Date
2/9/2024

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Comprehensive Stroke Center
Certification Decision
Effective Date
10/14/2023
Last Full Survey Date
10/13/2023
Last On-Site Survey Date
10/13/2023
Gold Seal
Ventricular Assist Device
Certification Decision
Effective Date
10/18/2023
Last Full Survey Date
10/17/2023
Last On-Site Survey Date
10/17/2023

Sites

Ambulatory Services OPD
948 48th Street
Brooklyn, NY, 11219

Available Services

  • Outpatient Clinics (Outpatient )

Ambulatory Surgery & Endoscopy Center
1025 48th Street
Brooklyn, NY, 11219

Available 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

Available Services

  • Perform Invasive Procedure (Outpatient )

Cancer Center of Brooklyn (Rad Onc/Hem Onc)
6300 8th Avenue
Brooklyn, NY, 11220

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Cardiology Outpatient
421 Ocean Parkway
Brooklyn, NY, 11218

Available Services

  • Outpatient Clinics (Outpatient )

Cardiology Outpatient
848 49th Street
Brooklyn, NY, 11220

Available Services

  • Outpatient Clinics (Outpatient )

Community Mental Health Center
920 48th Street
Brooklyn, NY, 11219

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Behavioral Health (Non 24 Hour Care - Child/Youth )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )

Maimonides Adult Primary Care Center
1250 57th Street
Brooklyn, NY, 11219

Available Services

  • Outpatient Clinics (Outpatient )

Maimonides Bay Ridge Emergency Department
9036 7th Avenue
Brooklyn, NY, 11209

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Maimonides Doctors Multispecialty Pavilion
4813 9th Avenue
Brooklyn, NY, 11220

Available Services

  • Outpatient Clinics (Outpatient )

Maimonides Medical Center
4802 Tenth Avenue
Brooklyn, NY, 11219

Available 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 )
  • 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 )
  • 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 )
  • Non-Sterile Medication Compounding (Inpatient )
  • 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 )
  • 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
  • Ventricular Assist Device

Maimonides Outpatient Rehabilitation Center
883 65th Street
Brooklyn, NY, 11220

Available Services

  • Outpatient Clinics (Outpatient )

MMC Sleep Lab
6405 7th Avenue - 3rd Floor
Brooklyn, NY, 11220

Available Services

  • Single Specialty Practitioner (Outpatient )

Newkirk Family Health Center
1401 Newkirk Avenue
Brooklyn, NY, 11230

Available Services

  • Outpatient Clinics (Outpatient )

Pediatric Dentistry
4305 13th Avenue
Brooklyn, NY, 11219

Available Services

  • Single Specialty Practitioner (Outpatient )

Pediatric Primary Care Center
1301 57th Street
Brooklyn, NY, 11219

Available Services

  • Single Specialty Practitioner (Outpatient )

Pre Admission Testing
745 64th Street
Brooklyn, NY, 11228

Available Services

  • Single Specialty Practitioner (Outpatient )

Primary Health Center
6323 Seventh Avenue
Brooklyn, NY, 11220

Available Services

  • Outpatient Clinics (Outpatient )

Women's Primary Care Services
4422 Ninth Avenue
Brooklyn, NY, 11220

Available Services

  • Outpatient Clinics (Outpatient )

Organization Commentary

Mr. Kenneth Gibbs, President and CEO

Organization Commentary: Maimonides Medical Center 4802 Tenth Avenue Brooklyn, NY 11219-2916 Chief Executive Officer: Kenneth D. Gibbs Maimonides Medical Center is dedicated to fostering healthy communities. We provide quality compassionate patient care and community services. As the leading academic medical center in Brooklyn, New York, we are also devoted to educating healthcare professionals, patients, families, employees and the communities we serve. We welcome participation in the Joint Commission Accreditation process as we continuously strive to reach new levels of excellence. This dedication is evident by continued success in meeting the stringent requirements of the accreditation process. We have also received Joint Commission’s Certification of Distinction for our Primary Stroke Center and our Ventricular Assist Device (VAD) Program. At Maimonides Medical Center, we understand and respect the diverse cultural needs and customs of our community and our staff. We continue our strong commitment to providing the highest quality, patient centered care to people of all faiths and backgrounds from the incredibly diverse population of Brooklyn and beyond.

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

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 2024 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Hospital-Based Inpatient Psychiatric Services National Comparison: nd 2 Statewide Comparison: nd 2
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.