Quality Report


Quality Report

Phelps Memorial Hospital Association
HCO ID: 5846
701 North Broadway
Sleepy Hollow, NY, 10591
(914) 366-3000
phelps.northwell.edu
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
12/16/2022
Last Full Survey Date
12/15/2022
Last On-Site Survey Date
12/15/2022
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/17/2022
Last Full Survey Date
12/16/2022
Last On-Site Survey Date
12/16/2022

Advanced Certification Programs

View Certification History
Gold Seal
Thrombectomy-Capable Stroke Center
Certification Decision
Effective Date
10/21/2022
Last Full Survey Date
8/10/2022
Last On-Site Survey Date
8/10/2022

Sites

Alcohol Treatment Services
22 Rockledge Avenue
Ossining, NY, 10562

Available Services

  • Addiction Services
  • Addiction Services (Non-detox - Adult )
  • Chemical Dependency (Day Programs - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Partial Hospitalization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • Family Support (Non 24 Hour Care )
  • Technology-Based Addiction Services (Non 24 Hour Care - Adult )
  • Technology-Based Addiction Services (Non-detox - Adult )

Phelps Continuing Day Treatment
315 South Highland Avenue
Briarcliff Manor, NY, 10510

Available Services

  • Behavioral Health (Day Programs - Adult )
  • Behavioral Health (Partial Hospitalization - Adult )
  • Community Integration (Non 24 Hour Care )

Phelps Counseling Services Ossining Branch
22 Rockledge Ave.
Ossining, NY, 10562

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Community Integration (Non 24 Hour Care )
  • Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )

Phelps Memorial Hospital Association
701 North Broadway
Sleepy Hollow, NY, 10591

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Brachytherapy (Imaging/Diagnostic Services )
  • Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
  • Chemical Dependency (Non-detox - Adult )
  • Community Integration (Non 24 Hour Care )
  • 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 )
  • 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 )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • 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 )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
  • Sleep Laboratory (Sleep Laboratory )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Thrombectomy-Capable Stroke Center

Phelps Memorial Hospital Center at Croton on Hudson
440 South Riverside Avenue
Croton On Hudson, NY, 10520

Available Services

  • Outpatient Clinics (Outpatient )

Phelps Memorial Hospital Center at Dobbs Ferry
11 Ashford Avenue
Dobbs Ferry, NY, 10522

Available Services

  • Outpatient Clinics (Outpatient )

Organization Commentary

Ms. Beata Mastalerz, Executive Director

Phelps Hospital is a full service community teaching hospital. Phelps hospital provides inpatient care which includes Surgery, Medicine, Orthopedics, Critical Care, Psychiatry, Pediatric, Maternal Child Health, Rehabilitation and Mental Health specialties. Our outpatient diagnostic services include a full service Radiology department with soon to be operational PET scan, Pulmonary and Cardiovascular diagnostic departments, a Speech and Hearing Center and a Sleep lab. Phelps outpatient care programs include a world-class Cancer Center, Hyperbaric Medicine, Wound Care, Physical and Occupational Therapy, Pain Management and Mental Health and Substances Abuse services. Advanced specialties also include Interventional Radiology, Bariatric Surgery and Neurosurgery, among others. As a proud member of the Northwell Health network, Phelps leverages the strengths of the largest health care network in New York State while providing care with a community centric approach. Phelps has achieved and maintained accreditation by the Joint Commission, the College of American Pathologists, Undersea and Hyperbaric Medical Society, the American College of Radiology and the Commission on Cancer. Phelps has achieved Magnet designation for nursing excellence. Additionally, Phelps has received designation as a Baby Friendly hospital, as well as NICHE designation as a leader in helping improve the care of patients 65 years old and older. Phelps has been recognized as one of the top hospitals in the region by US News and World Report. Phelps has achieved and maintained a prestigious 4 star rating from the Center for Medicare and Medicaid Services (CMS). Phelps continually strives to meet the needs of our community and provide quality care according to the highest standards in healthcare with compassion and expertise.

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 2022 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2022 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.