Accreditations & recognitions

In addition to being licensed by the New York State Department of Health and the New York State Department of Mental Health, Phelps Hospital has earned numerous accreditations and recognitions. For a complete list, see below.

Joint commission

Phelps Hospital is accredited by the Joint Commission, the leading accreditor of healthcare organizations in the United States. Joint Commission accreditation is recognized as a symbol of quality that reflects an organization’s commitment to meeting stringent performance standards.

In addition, Phelps has been recognized as a 2014 Top Performer in Key Quality Measures by the Joint Commission based on the hospital’s success in attaining and sustaining excellence in the following six areas of measurable performance: heart attack heart failure, pneumonia, surgical care, hospital-based psychiatric care and immunizations.

Highest level NICHE status for care of older adults

Phelps has achieved Exemplar status — the highest of four possible program levels — for its implementation of the NICHE (Nurses Improving Care for Healthsystem Elders) program,  based at NYU College of Nursing. Achieving NICHE designation indicates a hospital’s commitment to excellence in the care of patients 65 and older. Exemplar status recognizes Phelps’ ongoing, high-level dedication to geriatric care and pre-eminence in the implementation and quality of system-wide interventions and initiatives. Phelps is one of only three hospitals in Westchester and 10 in New York State to achieve this highest-level NICHE status.

Baby-friendly hospital

Phelps Hospital has always been known as a great place to have a baby, but now it has officially joined the international ranks of “Baby-Friendly® Hospitals,” recognized for offering an optimal level of care and support for new mothers and their babies. The Baby-Friendly Hospital Initiative (BFHI) is a global program created in 1991 by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). Phelps is the 16th hospital in New York State and only the second hospital in the Hudson Valley to achieve this designation.

Excellence in cancer care

Phelps has been granted an accreditation with commendation as a Community Hospital Cancer Program by the American College of Surgeons’ Commission on Cancer (CoC).

The CoC accreditation program helps facilities improve quality of patient care through various cancer-related programs focusing on the full spectrum of cancer care. These include prevention, early diagnosis, cancer staging, optimal treatment, rehabilitation, life-long follow up for recurrent disease, and end-of-life care. Patients who receive care at a CoC facility have access to information on clinical trials and new treatments, genetic counseling and patient-centered services including psycho-social support, a patient navigation process, and a survivorship care plan that documents each patient’s care and seeks to improve cancer survivors’ quality of life.

The chart below describes the prevention and screening activities that took place at Phelps Hospital in 2016:

Community outreach coordinator annual report 2016

Lung cancer screening center of excellence

Phelps has been designated a Lung Cancer Screening Center of Excellence by the Lung Cancer Alliance, joining a network of more than 250 screening centers across the U.S. committed to responsible lung cancer screening. The Lung Cancer Alliance is the oldest and leading non-profit organization dedicated to saving lives and advancing research by empowering those living with and at risk for lung cancer.

Each of the LCA Screening Centers of Excellence must commit to a number of guidelines based on best practices developed by professional bodies such as the American College of Radiology, the National Comprehensive Cancer Network and the Internal Early Lung Cancer Action Program.

Diagnostic imaging center of excellence

The Phelps Radiology Department has been designated a Diagnostic Imaging Center of Excellence by the American College of Radiology (ACR), recognizing its exemplary practices and diagnostic care. The designation involves a comprehensive assessment of the entire medical imaging enterprise, including the staff, technology and policies and procedures. Phelps was the 17th hospital in the country to receive this designation. To become a Diagnostic Imaging Center of Excellence, a facility must first have accreditation for all of the ACR-rated imaging services it provides. The Phelps Radiology Department performs a full spectrum of services for early detection and diagnosis of medical conditions. Services include bone densitometry, breast imaging, ultrasound, MRI, CT scan, nuclear medicine, angiography and diagnostic radiology.

Gold plus award for stroke care

Designated as a Stroke Center by the New York State Department of Health, Phelps annually attains the Gold Plus Performance Achievement Award — the highest recognition for quality stroke care — from the American Heart/American Stroke Associations.

The AHA/ASA’s “Get With the Guidelines-Stroke” program helps hospitals provide the most up-to-date, research-based treatments with the goal of speeding recovery and reducing death and disability for stroke patients. Phelps earns this award by meeting specific quality achievement measures for the diagnosis and treatment of stroke patients at a set level for a designated period.  These measures include the aggressive use of medications and risk-reduction therapies.

Cardiovascular diagnostic lab

The Phelps Cardiovascular Diagnostic Lab is accredited by the Intersocietal Accreditation Commission (IAC) in all of the echocardiography and vascular testing services it provides:

Vascular testing: extracranial cerebrovascular testing, peripheral arterial testing, peripheral venous testing

Echocardiography: adult transthoracic testing, adult transesophageal testing, adult stress testing

The IAC grants accreditation to those facilities found to be providing quality patient care in compliance with national standards. Vascular testing accreditation is required in some states and regions by the Centers for Medicare and Medicaid Services and by some private insurers.

Cardiac rehabilitation

The Cardiac Rehabilitation program at Phelps Hospital is certified by the American Association of Cardio Vascular and Pulmonary Rehabilitation (AACVPR). The AACVPR Cardiac and Pulmonary Rehabilitation Program Certification process is the only peer-review accreditation process designed to review individual facilities for adherence to standards and guidelines developed and published by AACVPR and other professional societies

Breast imaging center of excellence

The Breast Center at Phelps Hospital is designated a Breast Imaging Center of Excellence by the American College of Radiology. This designation is given to facilities that are fully accredited in and meet the highest national standards in mammography, stereotactic breast biopsy, breast ultrasound, ultrasound-guided breast biopsy and breast MRI.

Excellence in gastroenterology

The Phelps Medical Associates gastroenterology practice on the Phelps campus is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC). Status as an AAAHC-accredited organization means the practice has met nationally recognized standards for the provision of quality healthcare. Approximately 5,000 ambulatory healthcare organizations across the United States are accredited by AAAHC.

Hyperbaric medicine

The Hyperbaric Medicine Department at Phelps has achieved Level II “Accreditation with Distinction” as a clinical hyperbaric facility from the Undersea and Hyperbaric Medical Society (UHMS), an international non-profit organization serving more than 2,400 members from more than 50 countries. This accreditation with distinction recognizes that Phelps has exceeded the requirements of UHMS evaluation, demonstrating its strong commitment to patient care and facility safety. Areas examined include staffing and training, equipment installation, operation and maintenance, facility and patient safety, and standards of care.

Behavioral health programs

Phelps Hospital’s behavioral health programs are licensed by the New York State Office of Mental Health.

Substance abuse services

Phelps Hospital’s inpatient and outpatient substance abuse programs are licensed by the New York State Office of Alcoholism and Substance Abuse Services (OASAS).

Sleep center

The Sleep Center at Phelps Hospital is fully accredited by the American Academy of Sleep Medicine (AASM). This prestigious achievement shows that the Phelps Sleep Center is dedicated to the advancement of sleep medicine, and that it meets or exceeds all standards designated by the AASM in order to provide the highest quality of care for patients suffering from sleep disorders.

Diabetes education center recognition

The Phelps Diabetes Education Center has been recognized by the American Diabetes Association for meeting national standards for its high-quality diabetes self-management program. The center originally received this three-year recognition in July of 2010. The ADA’s Education Recognition program is the leading quality assurance mechanism for diabetes self-management programs across the country. Programs that achieve this status have a staff of knowledgeable health professionals who provide participants with comprehensive information about diabetes management. Appropriate self-management prevents unnecessary hospital admissions and some of the acute and chronic complications of diabetes.

American heart association fit-friendly worksite

Phelps Hospital has been named a Platinum-Level Fit-Friendly Worksite by the American Heart Association for helping employees eat better and move more. To achieve platinum-level status, Phelps reported its accomplishments in the areas of healthy eating and fitness.  Phelps’ Employee Wellness programs include free annual health screenings, on-site physical activities, walking competitions, free monthly smoking cessation classes, a gym reimbursement program and a series of educational programs on a variety of topics such as healthy eating and stress management.