Quality & Patient Safety

Providing a safe environment that respects all patients’ dignity, cultural, spiritual and psychosocial needs, Wyckoff Heights Medical Center takes pride in providing high quality "Care with Kindness".

The Joint Commission, an independent, not-for-profit organization, sets the standards to which Wyckoff Heights Medical Center measures its success.

Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

National Patient Safety Goals aim to improve patient safety and quality of care. The goals focus on problems in health care safety and how to solve them:

  • Identify patients correctly
  • Improve staff communication
  • Use medicines safely
  • Use alarms safely
  • Prevent infection
  • Identify patient safety risks
  • Prevent mistakes in surgery

Questions to Ask About Your Care

Nobody knows you better than yourself! Speak up! Ask questions. Our Doctors, Nurses and Staff are seeking your participation and your collaboration in the decisions regarding your care. Ask questions, voice your concerns, and address any issues relating to your care, your treatment and overall hospital services.

STEP UP & SPEAK UP

Speak Up – Ask questions and voice your concerns. It’s your body and you have a right to know.

Pay Attention – Make sure you’re getting the right treatment and medicine.

Educate Yourself – Learn about the medical tests ordered for you and request to discuss your treatment plan.

Find An Advocate – Pick a trusted family member or friend to be your advocate or support person.



CONCERNS?

If you have concerns about the care you or your family member receives, please speak with your physician, patient care manager or clinic manager. Feel free to call the patient advocate department at 718-963-7189.

If you feel that your issue was not resolved to your satisfaction, the New York State Department of Health (DOH) may be reached by phone at 800-804-5447 or in writing at New York State Department of Health Centralized Hospital Intake Program, 433 River St., 6th floor, Troy, NY 12180.

Quality & Patient Safety Performance Reports

Wyckoff Heights Medical Center is committed to the delivery of the best Quality of Care and Service Excellence for all patients and their families.

  • Timely & Effective Care
    Wyckoff Heights Medical Center’s mission is to be the health system of, by, and for the community. Provision of "Care with Kindness" is essential to this mission. Accordingly, all departments and clinical services develop protocols that are clinically sound and reflect current evidence based best practices.

    Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services (CMS)- Opens in a new window, in collaboration with organizations representing consumers, hospitals, doctors, employers, accrediting organizations, and other federal agencies.

    They identify opportunities to improve patient care, to enhance organizational performance and reduce potential risks to patients. These measures show how often hospitals provide care that research shows gets the best results for patients with certain conditions: heart attack care, heart failure care, pneumonia care, surgical care, emergency department care, preventive care, stroke care, blood clot prevention & treatment and pregnancy & delivery care.

    HOSPITAL PERFORMANCE REPORT

    Measure DescriptionWYCKOFFNYS AVGNATIONAL AVG
    TIMELY AND EFFECTIVE CARE  
    Heart Attack Care 7/1/2014-6/30/2015
    Average (median) number of minutes before outpatients with chest pain or possible heart attack got an ECG 10 Minutes 10 Minutes 7 Minutes
    Outpatients with chest pain or possible heart attack who received aspirin within 24 hours of arrival or before transferring from the emergency department 100% 97% 97%
    Heart failure Care      
    Heart failure patients given an evaluation of left ventricular systolic (LVS) function 100% 99% 99%
    Pneumonia Care      
    Pneumonia patients given the most appropriate initial antibiotic(s) 98% 96% 95%
    Timely Surgical Care      
    Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection 98% 99% 99%
    Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) 100% 98% 98%
    Patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery 100% 100% 100%
    Surgical Care      
    Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery 93% 98% 98%
    Surgery patients who were given the right kind of antibiotic to help prevent infection 92% 98% 99%
    Surgery patients whose urinary catheters were removed on the first or second day after surgery 96% 98% 98%
    Eemergency Department Care      
    Average (median) time patients who came to the emergency department with broken bones had to wait before getting pain medication 132 Minutes 59 Minutes 54 Minutes
    Percentage of patients who left the emergency department before being seen 4% 2% 2%
    Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient 448 Minutes 492 Minutes 343 Minutes
    Average (median) time patients spent in the emergency department, after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room 181 Minutes 188 Minutes 134 Minutes
    Average (median) time patients spent in the emergency department before leaving from the visit 172 Minutes 202 Minutes 173 Minutes
    Average (median) time patients spent in the emergency department before they were seen by a healthcare professional 83 Minutes 47 Minutes 33 Minutes
    Stroke Care      
    Ischemic stroke patients who got medicine to break up a blood clot within 3 hours after symptoms started 81% 82% 83%
    Ischemic stroke patients who received medicine known to prevent complications caused by blood clots within 2 days of hospital admission 95% 99% 98%
    Ischemic or hemorrhagic stroke patients who received treatment to keep blood clots from forming anywhere in the body within 2 days of hospital admission 95% 97% 97%
    Ischemic stroke patients who received a prescription for medicine known to prevent complications caused by blood clots at discharge 99% 99% 99%
    Ischemic stroke patients needing medicine to lower bad cholesterol, who were given a prescription for this medicine at discharge 95% 97% 97%
    Ischemic or hemorrhagic stroke patients or caregivers who received written educational materials about stroke care and prevention during the hospital stay 98% 94% 94%
    Ischemic or hemorrhagic stroke patients who were evaluated for rehabilitation services 96% 98% 98%
    Pregnancy and Deliveries      
    Percent of mothers whose deliveries were scheduled too early (1-2 weeks early), when a scheduled delivery was not medically necessary 92% 2% 3%
    Blood Clot Treament      
    Patients with blood clots who got the recommended treatment, which includes using two different blood thinner medicines at the same time 88% 94% 95%
    Patients with blood clots who were treated with an intravenous blood thinner, and then were checked to determine if the blood thinner caused unplanned complications 100% 96% 99%
    Patients with blood clots who were discharged on a blood thinner medicine and received written instructions about that medicine 77% 89% 91%
    Blood Clot Prevention      
    Patients who got treatment to prevent blood clots on the day of or day after hospital admission or surgery 93% 94% 93%
    Patients who got treatment to prevent blood clots on the day of or day after being admitted to the intensive care unit (ICU) 98% 96% 97%
    Patients who developed a blood clot while in the hospital who did not get treatment that could have prevented it 0% 4% 4%
    Preventive care 10/1/2014-3/31/2015
    Patients assessed and given influenza vaccination 98% 91% 94%
    Healthcare workers given influenza vaccination 80% 84% 84%
    COMPLICATIONS      
    Surgical Complications 7/1/2012-6/30/2014
    Serious complications (From AHRQ) No Different than the National Rate   0.81
    Surgical Complications  
    Central line-associated bloodstream infections (CLABSI) in ICUs only No Different than National Benchmark 0.426 1
    Catheter-associated urinary tract infections (CAUTI) in ICUs only No Different than National Benchmark 0.857 1
    Surgical site infections from colon surgery (SSI: Colon) No Different than National Benchmark 1.363 1
    Methicillin-resistant Staphylococcus Aureus (MRSA) Blood Laboratory-identified Events (Bloodstream infections) No Different than National Benchmark 0.957 1
    Clostridium difficile (C.diff.) Laboratory-identified Events (Intestinal infections) Better than the National Benchmark 0.88 1
    Central line-associated bloodstream infections (CLABSI) in ICUs and select wards No Different than National Benchmark 0.608 1
    Catheter-associated urinary tract infections (CAUTI) in ICUs and select wards No Different than National Benchmark 0.677 1
    30-Day Unplanned Readmissions & Death 7/1/2011-6/30/2014
    COPD Readmission Rate Worse than the National Rate   20.20%
    Heart Attack Readmission Rate No different than the National Rate   17.00%
    Heart Failure Readmission Rate No different than the National Rate   22.00%
    Pneumonia Readmission Rate Worse than the National Rate   16.90%
    Stroke Readmission Rate Worse than the National Rate   12.70%
    COPD Mortality Rate No different than the National Rate   7.70%
    Heart Attack Mortality Rate No different than the National Rate   14.20%
    Heart Failure Mortality Rate No different than the National Rate   11.60%
    Pneumonia Mortality Rate No different than the National Rate   11.50%
    Stroke Mortality Rate No different than the National Rate   14.80%
    30-Day Unplanned Hospitalwide Readmissions 7/1/2013-6/30/2014
    Rate of unplanned readmission after discharge from hospital (hospital-wide) Worse than the National Rate   15.20%

    For detailed hospital compare data, visit https://www.medicare.gov/hospitalcompare.

  • Readmissions and Deaths
    Some patients who are admitted to the hospital may experience complications shortly after discharge and need to return and are sometimes re-admitted. Wyckoff Heights Medical Center is working to reduce the number of readmissions. Readmissions are reviewed and addressed in a time sensitive manner.

  • HIV and Hepatitis C management
    While much progress has been made over the years in improving access to HIV testing and treatment, New Yorkers continue to bear a disproportionate burden of HIV:

    In 2014, nearly 120,000 people were living with HIV in New York City (NYC), of which 2,718 were newly diagnosed.

    Similarly, Hepatitis C (HCV) is a serious health concern for New Yorkers with an estimated 146,000 people aged 20 or older living with HCV and 7,691 people newly reported with HCV in 2014. However, it is estimated that as many as 21% of New Yorkers living with HIV and 50% of New Yorkers living with Hepatitis C do not yet know their status.

    Wyckoff Heights Medical Center (Wyckoff) is committed to the New York State and New York City goals of helping New Yorkers learn their HIV and HCV status and access the latest treatments for HIV and HCV that can help them live healthful and long lives. Wyckoff has been providing HIV testing and treatment since 1996, and since 2013 has been making HIV testing routinely available in all hospital settings including the Emergency Room, in ambulatory care clinics and on the inpatient floor. Wyckoff has also been offering routine HCV testing hospital-wide since 2015 and currently provides the newest and best Hepatitis C treatments available which have been proven to be much better tolerated and extremely effective in curing the disease. Since 2013, Wyckoff has helped nearly 30,000 New Yorkers learn their HIV status and since 2015, we have informed 5,559 New Yorkers of their Hepatitis C status. Wyckoff assisted 178 people who tested HIV positive and 95 people who tested Hepatitis C positive at Wyckoff access the best care available, ensuring that they can stay healthy and well.

    25,076 HIV Tests
    158 HIV Positive
    59 Newly diagnosed (8 acute HIV diagnoses)
    54 linked to care within 90 days
    5,559 HCV tests
    310 HCV AB+
    95 HCV RNA+
    58 RNA+ linked to care
  • Infection Control
    Wyckoff Heights Medical Center strives to prevent the spread of infection, which can proliferate through the air, by contact with hands, personal items, or in droplets from coughs and sneezes. Prevention measures include hand washing, isolation techniques, equipment sterilization and best practices.

  • Flu Vaccine
    Patients/Family and staff are encouraged to take the Flu vaccines during the months of October through March. Please contact your provider to schedule your vaccination.

  • Fall Reduction Program
    Wyckoff Height Medical Center has implemented a fall reduction program for patients at high risk for falls. Several measures were executed to lessen the number of falls.

Accreditation

Wyckoff Heights Medical Center is Joint Commission accredited.

Process Improvement

PI Methodologies-Change Management Models

Stroke Award 2012-2016

Stroke Award 2012-2016

Wyckoff Heights Medical Center’s Stroke Program, for the 5th consecutive year, has been awarded one of the highest distinctions from the American Heart Association/American Stroke Association – The 2016 Get With The Guidelines® - Stroke Gold Plus Quality Achievement Award with Target: Stroke Honor Roll. The award recognizes the hospital’s commitment and success ensuring that stroke patients receive the most appropriate treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence.

To receive the Gold Plus Quality Achievement Award, 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 achieved 75 percent or higher compliance with five of eight Get With The Guidelines-Stroke Quality measures.

To qualify for the Target: Stroke Honor Roll, 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 (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. Wyckoff Heights earned the award by meeting specific quality achievement measures 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 provide the most up-to-date, evidence-based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients.

This award is attributable to the hard work and dedication of the Wyckoff Stroke Care Team, which is comprised of personnel from numerous departments, including ED and inpatient nurses, physicians, and PAs, neurologists, the radiology team, the laboratory/pathology team, the pharmacy team, and our quality assurance team.