Staten island university hospital labor and delivery

Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually.

Volume may be impacted by COVID-19 and may not reflect regular operations.

This hospital performed 77 carotid artery surgeries compared to Leapfrog’s standard of 20 procedures annually.

As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery.

Additionally, this hospital does not have protocols in place to ensure that carotid artery surgeries are only performed on patients that meet defined criteria.

Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. In addition, hospitals should participate in a national clinical registry and achieve the same or better outcomes when compared to others who also perform this procedure.

Volume may be impacted by COVID-19 and may not reflect regular operations.

This hospital performed 32 mitral valve repairs and replacements compared to Leapfrog’s standard of 40 procedures annually.

As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for mitral valve repair and replacement.

This hospital does participate in the Society of Thoracic's Surgeons Adult Cardiac Surgery Database.

This hospital's outcome (absence of mortality and major morbidity) for mitral valve repairs and replacements is: As Expected.

Additionally, this hospital does not have protocols in place to ensure that mitral valve repairs and replacements are only performed on patients that meet defined criteria.

Hospitals should perform at least 10 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually.

Volume may be impacted by COVID-19 and may not reflect regular operations.

This hospital performed 32 open aortic procedures compared to Leapfrog’s standard of 10 procedures annually.

As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for open aortic procedures.

Additionally, this hospital does not have protocols in place to ensure that open aortic procedures are only performed on patients that meet defined criteria.

Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually.

Volume may be impacted by COVID-19 and may not reflect regular operations.

This hospital performed 148 bariatric surgeries for weight loss compared to Leapfrog’s standard of 50 procedures annually.

As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for bariatric surgeries for weight loss.

Additionally, this hospital does not have protocols in place to ensure that bariatric surgery for weight loss is only performed on patients that meet defined criteria. 

Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. 

Volume may be impacted by COVID-19 and may not reflect regular operations.

This hospital performed 3 esophageal resections for cancer compared to Leapfrog’s standard of 20 procedures annually.

As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for esophageal resection for cancer.

Additionally, this hospital does indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that esophageal resections for cancer are only performed on patients that meet defined criteria.

Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually.

Volume may be impacted by COVID-19 and may not reflect regular operations.

This hospital performed 32 lung resections for cancer compared to Leapfrog’s standard of 40 procedures annually.

As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 15 procedures annually for lung resection for cancer.

Additionally, this hospital does indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that lung resections for cancer are only performed on patients that meet defined criteria.

The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. 

Volume may be impacted by COVID-19 and may not reflect regular operations.

This hospital performed 9 pancreatic resections for cancer compared to Leapfrog’s standard of 20 procedures annually.

As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for pancreatic resection for cancer. 

Additionally, this hospital does indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that pancreatic resections for cancer are only performed on patients that meet defined criteria.

Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 6 procedures annually.

Volume may be impacted by COVID-19 and may not reflect regular operations.

This hospital performed 9 rectal cancer surgeries compared to Leapfrog’s standard of 16 procedures annually.

As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 6 procedures annually for rectal cancer surgery.

Additionally, this hospital does indicate having national accreditation from the American College of Surgeons or a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that rectal cancer surgery is only performed on patients that meet defined criteria.

Hospitals should perform at least 8 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 5 procedures annually.

Volume may be impacted by COVID-19 and may not reflect regular operations.

Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a surgery is performed.

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