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Accreditations/Recognition
St. Luke's Cornwall Hospital is committed to quality, and is accredited by several organizations that set health care standards and monitor performance.
 
Quality Recognitions:
 
 
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Healthgrades® Five Star Recipient 

Healthgrades® has recognized St. Luke’s Cornwall Hospital for its high quality patient care. We have receieved this recognition in Natural Childbirth for three consecutive years (2015-2017). This 5-star rating indicates that the hospital’s clinical outcomes are statistically significantly better than expected when treating the condition or performing the procedure being evaluated. Providing quality care to our patients is our number one priority.


 

St. Luke's Cornwall Hospital Newburgh campus is designated as a Blue Distinction Center for Knee and Hip Replacement by Empire Blue Cross Blue Shield, an independent licensee of Blue Cross Blue Shield Association.

Empire BlueCross BlueShield has selected St. Luke's Cornwall Hospital as a Blue Distinction Center for Knee and Hip Replacement, part of the Blue Distinction Specialty Care program. The SLCH Center for Joint Replacement is led by Medical Director, John McLaughlin, MD, and offers the full gamut of joint replacement including the knee, hip, and shoulder; performed by a highly trained, qualified team of orthopedic surgeons on the staff of SLCH. 

 

As a Blue Distinction Center for Knee and Hip Replacement, SLCH demonstrates expertise in total knee and total hip replacement surgeries, resulting in fewer patient complications and hospital readmissions.

 

With this designation, SLCH's Center for Joint Replacement is a nationally designated healthcare facility shown to deliver improved patient safety and better health outcomes, based on objective measures that were developed by Blue Cross and Blue Shield companies with input from the medical community.

 

St. Luke's Cornwall Hospital's Newburgh campus is designated as a Blue Distinction Center for Maternity Care by Empire Blue Cross Blue Shield, an independent licensee of Blue Cross Blue Shield Association.

Empire Blue Cross Blue Shield has selected St. Luke's Cornwall Hospital as a Blue Distinction Center for Maternity Care. With this designation, SLCH is nationally recognized for providing maternity services that are family centered, promote successful breastfeeding and culturally competent care. Additionally, we work with each patient to connect mother and baby to all appropriate community resources. Our team provides compassionate care to the community we serve. We are with you for life from the very beginning.

 

St. Luke’s Cornwall Hospital's Institute for Metabolic and Bariatric Surgery has been accredited as a Comprehensive Center under the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®), a joint program of the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS). 

 
SLCH officially launched the service in January 2015, treating patients throughout the Hudson Valley at the hospital’s Newburgh and Cornwall campuses. With this accreditation, patients seeking surgical treatment for severe obesity and its related conditions have a high-quality choice for receiving care at a nationally accredited program that meets the highest standards for patient safety and quality of care in the greater Hudson Valley Region area. 

The MBSAQIP Standards, outlined in the Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2016 ensure that bariatric surgical patients receive a multidisciplinary program, not just a surgical procedure, which improves patient outcomes and long-term success. SLCH’s accredited center offers preoperative and postoperative care designed specifically for their bariatrics patients.

To earn the MBSAQIP designation, SLCH met essential criteria for staffing, training, facility, infrastructure and protocols for care, ensuring its ability to support patients with severe obesity. SLCH’s Institute for Metabolic and Bariatric Surgery also participates in a national data registry that yields semiannual reports on the quality of its processes and outcomes, identifying opportunities for continuous quality improvement. The standards are specified in the MBSAQIP Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2016, published by the ACS and ASMBS.

 
After submitting an application, centers seeking MBSAQIP Accreditation undergo an extensive site visit by an experienced bariatric surgeon, who reviews the center's structure, process, and clinical outcomes data. Centers are awarded a specific designation depending on how many patients it serves annually, the type of procedures it provides, and whether it provides care for patients under age 18. SLCH received outstanding remarks from its survey earlier this year, which included acknowledgement of the team’s leadership and excellent clinical outcomes.


 

Level III Trauma Center

The trauma center at St. Luke's Cornwall Hospital has been verified as a Level III Trauma Center through 2019 by the Verification Review Committee (VRC), an ad hoc committee of the Committee on Trauma (COT) of the American College of Surgeons (ACS). This achievement recognizes the trauma center's dedication to providing optimal care for injured patients.

 

The SLCH Trauma Program officially began in May 2014, allowing the hospital to operate provisionally as an Area Trauma Center. Since that time, the SLCH trauma team has treated more than 1,000 patients, implementing policies and procedures designed to enhance the care provided to patients in need of trauma services.

 

In November 2016, SLCH had its trauma verification survey conducted by the American College of Surgeons Committee on Trauma. SLCH is the first hospital in New York State to receive a Level III trauma designation as a first time trauma center and is the only verified Level III Trauma Center in the Hudson Valley.

 

SLCH is proud to partner with Surgical Affiliates Management Group (SAMGI) in the management of SLCH's Trauma surgeons, Nurse Practitioners and Physician Assistants. This dynamic team assists in the management of trauma patients in all areas of the hospital during a patients stay. The Trauma Program has bolstered the Kaplan Family Center for Emergency Medicine and the Emergency Department team as it continues to provide comprehensive, high-quality emergent care to patients and their families throughout the community.

 

Verified trauma centers must meet the essential criteria that ensure trauma care capability and institutional performance, as outlined by the American College of Surgeons' Committee on Trauma.

 

The SLCH Level III Trauma Center provides a multitude of services both within the walls of the hospital and in the community including community education to prevent trauma injuries such as "Not One More"-Teen Traffic Safety Program and a Falls Prevention Program.

 

The Consultation/Verification Program for Hospitals promotes the development of trauma centers in which participants provide not only the hospital resources necessary for trauma care, but also the entire spectrum of care to address the needs of all injured patients. This spectrum encompasses the prehospital phase through the rehabilitation process.

 

To date, the program has seen close to 900 trauma patients who were able to receive excellent care faster and closer to home, undoubtedly leading to better outcomes. The Trauma Program has bolstered the Kaplan Family Center for Emergency Medicine as it continues to provide comprehensive, high-quality emergent care to our patients and their families.

 

 

2017 Pioneer in Quality Expert Contributor

by The Joint Commission


The Joint Commission has recognized St. Luke's Cornwall Hospital as a 2017 Pioneers in Quality™ Expert Contributor for its contributions to electronic clinical quality measure (eCQM) data for quality improvement in health care.

 

SLCH is one of just nine hospitals recognized by The Joint Commission in 2017 for contributing eCQM knowledge and utilization practices for sharing with other accredited hospitals.

 

Until recently, most hospitals collected information to measure health care quality by manually abstracting data from patient records. Today, through eCQMs—which rely on structured, encoded data present in the electronic health record—hospitals can electronically collect and transmit data on the quality of care that patients receive. The electronic data can be analyzed to measure and improve care processes, performance and outcomes.

 

The Joint Commission, the United States’ leading accreditor of health care organizations, established the Pioneers in Quality™ program to assist and recognize hospitals that report eCQM data, as well as share best practices for all hospitals in gathering, analyzing and leveraging eCQM data for quality improvement.

 

St. Luke's Cornwall Hospital Earns 'Top Performer' Recognition from The Joint Commission

We are pleased to announce that in November 2014, The Joint Commission recognized St. Luke’s Cornwall Hospital as a 2013 Top Performer on Key Quality Measures®. St. Luke’s Cornwall Hospital has been recognized for its excellence in management of Heart Attack, Heart Failure, Stroke and Surgical Care. This distinction is provided to hospitals that have achieved 95% compliance or more for all reported accountability measures to the Joint Commission, demonstrating evidenced based care in these patient populations.   St. Luke’s Cornwall Hospital is one of only 1,224 hospitals in the United States to achieve the distinction as a 2013 Top Performer.


 

“The quality of care provided to our patients as well as their safety are extremely important to our entire healthcare team at St. Luke’s Cornwall Hospital,” said Robert S. Ross, SLCH President and CEO.  “Consistent use of evidence based care is a key element to improving patient outcomes. We are proud to be named a Top Performer as it recognizes the knowledge, teamwork and dedication of our entire staff.”


 

For more information about the Top Performer program, including eligibility criteria, visit http://www.jointcommission.org/accreditation/top_performers.aspx.

 

American Stroke Association Recognition:​

St. Luke's Cornwall Hospital has received the American Heart Association/American Stroke Association's Get With The Guidelines®-Stroke Gold Plus Achievement Award with Target: StrokeSM Honor Roll Elite Plus. The award recognizes the hospital's commitment to providing the most appropriate stroke treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence.

 

This is the eighth consecutive year that SLCH has received the Gold plus award and the first year receiving the distinction of Target: Stroke Honor Roll Elite Plus. Hospitals must achieve 85 percent or higher adherence to all Get With The Guidelines-Stroke achievement indicators for two or more consecutive 12-month periods and achieve 75 percent or higher compliance with five of eight Get With The Guidelines-Stroke Quality measures to receive the Gold Plus Quality Achievement Award.

 

To qualify for the Target: Stroke Honor Roll Elite Plus, hospitals must meet quality measures developed to reduce the time between the patient's arrival at the hospital and treatment with the clot-buster tissue plasminogen activator, or tPA, the only drug approved by the U.S. Food and Drug Administration to treat ischemic stroke. If given intravenously in the first three hours after the start of stroke symptoms, tPA has been shown to significantly reduce the effects of stroke and lessen the chance of permanent disability. SLCH earned the award by meeting specific quality achievement measure​s for the diagnosis and treatment of stroke patients at a set level for a designated period.

 

These quality measures are designed to help hospital teams follow the most up-to-date, evidence-based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients.​


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2017 Health Care's Most Wired

For the fourth straight year, St. Luke’s Cornwall Hospital (SLCH) has been included on the list of Health Care’s Most Wired® hospitals, ranking among the nation’s best in using information technology to improve patient care.  

 

 

New tools are helping patients become more actively involved in their care and maintaining their health, according to results of the 19th Annual Health Care’s Most Wired® survey, released by the American Hospital Association’s (AHA) Health Forum. SLCH has worked diligently to enhance its information technology infrastructure throughout the last four years, making it easier for patients, as well as providers to access necessary data in timely and convenient fashion. 
 
According to the survey, Most Wired hospitals are using smart phones, telehealth and remote monitoring to create more ways for patients to access health care services and capture health information. 

 
Most Wired hospitals are transforming care delivery with knowledge gained from data and analytics.  They are investing in analytics to support new delivery models and effective decision-making and training clinicians on how to use analytics to improve quality, provide access and control costs.

 
HealthCare’s Most Wired® survey, conducted between Jan. 15 and March 15, 2017, is published annually by Hospitals & Health Networks (H&HN). The 2017 Most Wired® survey and benchmarking study is a leading industry barometer measuring information technology (IT) use and adoption among hospitals nationwide. The survey of 698 participants, representing an estimated 2,158 hospitals — more than 39 percent of all hospitals in the U.S. — examines how organizations are leveraging IT to improve performance for value-based health care in the areas of infrastructure, business and administrative management; quality and safety; and clinical integration. 


 

Aetna Institute of Quality® For Cardiac Care  
Aetna Institute of Quality® (IOQ) for Cardiac Care
St. Luke's Cornwall Hospital has been designated as an Institute of Quality® for Cardiac Medical Intervention by Aetna. SLCH was chosen as an Aetna Designated IOQ facility because we demonstrate excellence in care, a commitment to continuous improvement and represent an exceptional value to our patients.                                        
 
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Accreditations:

Undersea and Hyperbaric Medical Society
The St. Luke's Cornwall Center for Wound Healing and Hyperbaric Medicine has been named an accredited facility by the Undersea and Hyperbaric Medical Society. The UHMS investigates twenty two separate and detailed topics in the operations hyperbaric medicine center.  Our facility has met the standard for Administration, Facility, Governance, Patient Care, Quality and Safety. 

Since 2001, the UHMS has a clinical hyperbaric medicine facility accreditation program. Clinical hyperbaric facilities can demonstrate their commitment to patient care and facility safety by voluntarily participating in this program. When invited to perform an accreditation survey, the UHMS will send a team of experts to the facility to examine staffing and training, equipment installation, operation, and maintenance, facility and patient safety, and standards of care.


 

The Joint Commission 

                                   
The Joint Commission:
SLCH is committed to providing quality care, and has earned a gold seal from The Joint Commission. This includes both hospital campuses, as well as our outpatient satellite services. The Commission sets the standards by which health care quality is measured in the U.S
 
 
Commison on Cancer Accrediation by the American College of Surgeons  
Commission on Cancer Accreditation by the American College of Surgeons (CoC):
The oncology program at SLCH is accredited by the American College of Surgeons’ Commission on Cancer. Fewer than one in four hospitals that treat cancer receive this coveted approval, which is granted only to those facilities that have voluntarily committed to providing "the highest level of quality cancer care" and that undergo a rigorous evaluation process and review of their performance. The accreditation applies to both the Cornwall and Newburgh campuses.
 
According to the Commission, receiving care at an approved cancer program ensures patients will have access to "comprehensive care, including state-of-the-art services and equipment; a multi specialty team approach to coordinate the best treatment options; information about cancer clinical trials and new treatment options; access to cancer-related information, education, and support; a cancer registry that offers lifelong patient follow-up; ongoing monitoring and improvement of care; and most importantly, quality care close to home."
 
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American Diabetes Association:
The diabetes self-management program at St. Luke’s Cornwall Hospital (SLCH) has been awarded recognition by the American Diabetes Association (ADA). Education recognition is presented to health care sites that meet national standards for Diabetes Self-Management Education (DSME). For more information about this accreditation,
click here.

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College of American Pathology (CAP):
The College of American Pathology’s Laboratory Accreditation is widely recognized as setting the “gold standard” for laboratory services. The laboratories at both the Cornwall and Newburgh campuses are accredited by CAP, with recertification required every two years.


 


American Academy of Sleep Medicine:

The St. Luke's Cornwall Center for Sleep Medicine (Cornwall Campus) has earned accreditation from the American Academy of Sleep Medicine (AASM).  The AASM is the leader in setting standards and promoting excellence in sleep medicine health care, education and research. The AASM sets the clinical standards for sleep medicine.  They advocate for the recognition, diagnosis and treatment of sleep disorders as well as educate professionals dedicated to providing optimal sleep health care. 

 

The AASM acknowledges facilities across the nation that provides only the highest quality of care. The SLC Center for Sleep Medicine is a facility that not only provides quality diagnostic services but also effective treatment methods for its patients.

 

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American College of Radiology (ACR):
SLCH has earned accreditation from The American College of Radiology. With more than 32,000 members, the ACR is a professional society whose primary purpose is to improve services to patients, advance the science of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists and persons practicing in the allied professional fields. Areas of accreditation include: CT scan at the Cornwall and Newburgh campus, as well as ultrasound, nuclear medicine and mammography at the Newburgh campus.
 
 
American Association of Cardiovascular and Pulmonary Rehabilitation  
American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR):
The AACVPR has awarded SLCH's Cardiac Rehabilitation Program recertification with the distinction of excellence. Certification recognizes those programs reviewed by a national board and found to uphold rigorous standards of care designed to limit the physiological and psychological effects of cardiac illness; reduce the risk for sudden death or relapse; control cardiac symptoms; stabilize and/or improve health; and enhance the patient's quality of life.
 
  
Other:
In addition to voluntary accreditation, our services are also monitored by state and regulatory agencies, including:
  • New York State Department of Health
  • New York State Department of Health-Bureau of Environmental Radiation Protection
  • Livanta is the Beneficiary and Family Centered Care Quality Improvement Organization that manages case review activities (i.e., all beneficiary complaints/quality of care reviews, higher weighted DRG validation and non-coverage appeals) for the Centers for Medicare and Medicare Services (CMS). Their toll free number is (866) 815-5440. 
 
Should you have a concern about patient care or safety at SLCH, please contact a member of our management team in order to discuss your concern. If it cannot be resolved by the hospital staff or management team, you may call the Joint Commission's Office of Quality Monitoring at (800) 994-6610, or e-mail complaint@jointcommission.org.

You may contact the New York State Department of Health by mail or by phone.The toll free number is (800) 804-5447 or you may file a complaint in writing and send it to:

New York State Department of Health
Centralized Hospital Intake Program
Mailstop: CA/DCS
Empire State Plaza
Albany, NY 12237
For questions or comments, you can e-mail the Department of Health at hospinfo@health.state.ny.us