Quality and Satisfaction Initiatives

Quality of care is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”
The Joint Commission

Deborah Heart and Lung Center is committed to quality care. Our vision is to be known for excellent clinical outcomes, for supreme customer-driven service, and as the ultimate leader in patient safety and privacy. We partner with quality providers and payers to ensure a seamless continuum of care to the patients we serve and continuously seek to improve both service and quality in the most cost-effective manner.

Deborah uses the Continuous and Total Quality Improvement models to perform and evaluate vital processes that affect patient care at the Center. We involve our entire organization in a continuous process of customer driven quality improvement activities.

Our commitment is exemplified by our participation in a number of federal, state and privately supported quality programs. We voluntarily collect and submit data to a number of external programs.

We are proud of our performance and ranking at both National and State levels for our management of heart, lung and vascular diseases.

Deborah Heart and Lung Center has earned The Joint Commission’s Gold Seal of Approval!

What is The Joint Commission?

The Joint Commission on Accreditation of Healthcare Organizations is an independent, not-for-profit organization, est. over 50 years ago. Joint Commission is governed by a board that includes physicians, nurses, and consumers. It sets the standards by which health care quality is measured here and around the world.

Joint Commission evaluates the quality and safety of care for over 15,000 health care organizations. To maintain and earn accreditation, organizations must have an extensive on-site review by a team of Joint Commission health care professionals, at least once every three years. The purpose of the review is to evaluate the organization’s performance in areas that affect your care. Accreditation is awarded based on how well the organization met Joint Commission standards. The accreditation process requires hospitals to submit data for specified performance measures:

  • Patient Safety Goals
  • Acute Myocardial Infarction Management
  • Heart Failure Care

If any individual has any concerns about patient care and safety in the hospital that the hospital has not addressed, he/she is encouraged to contact the hospital’s management through Administration at the hospital. If the concerns cannot be resolved through the hospital, he/she is encouraged to contact the Joint Commission by either calling 1-800-994-6610 or emailing complaint@jcaho.org.

Hospital Results for Heart Attack Care: Deborah has achieved outstanding compliance scores of 96% to 100%.

Hospital Results for Heart Failure Care: Deborah has achieved outstanding compliance scores of 90% to 100% for heart failure care.

Hospital Results for National Patient Safety Goals: Deborah has met with required compliance for all the specified national patient safety goals.

New Jersey Report Card

Hospitals submit data to the New Jersey Department of Health and Senior Services for public reporting as part of the State’s hospital quality performance initiative to provide information on hospital quality to patients, families and healthcare professionals. Deborah Heart and Lung Center voluntarily submits data to the New Jersey State Department of Health and Human Services public reporting division for the following performance measures:

  • Acute Myocardial Infarction Management
  • Heart Failure Management


The Leapfrog Group is an organization comprised of over 170 companies and organizations who are made up of Fortune 500 companies and other large private and public organizations that provide health benefits for their employees, retirees and dependents. Leapfrog Group together spends nearly $67 billion each year on health care for 36 million Americans in all 50 states. This Group represents a significant purchasing power in the healthcare industry, the purpose of which is to use the way they purchase health care to influence hospitals to improve the safety, quality and affordability of healthcare for Americans. This is achieved by rewarding hospitals who successfully implement health care safety, quality and customer value.

We voluntarily complete the Leapfrog Survey for public reporting for the following performance measures:

  1. Hospital requires the use of computers to order medications, tests and procedures. This is called a Computerized Physician Order Entry system (CPOE). This prevents errors in ordering. Deborah Heart and Lung Center has achieved the highest score “fully implemented” for this measure.
  2. Hospital has an intensive care unit (ICU) that is staffed by doctors and other caregivers who have special training in critical care. These are doctors are called “intensivists.”Deborah Heart and Lung Center has achieved the highest score “fully implemented” for this measure.
  3. Hospital has lots of experience and the best results for specific procedures, surgeries/ conditions. This is known as Evidence Based Hospital Referral (High risk procedures).Deborah Heart and Lung Center has achieved the second highest score “Good Progress” for this measure.
  4. Hospital has a high Leapfrog Safe Practices Score. This means it has put in place 27 procedures to reduce preventable medical mistakes. Deborah Heart and Lung Center has achieved the second highest score “Good Progress” for this measure.

Deborah’s Results

National Hospital Compare Report

National Hospital Compare Report is a national quality initiative sponsored by the Hospital Quality Alliance. This Alliance is a public-private group effort that includes the Centers for Medicare and Medicaid Services (CMS) and the American Hospital Association and other nationally recognized organizations. This initiative is designed to “improve care through information to improve the quality of care provided by the nation’s hospitals by measuring and publicly reporting on that care.”

We voluntarily submit data to this national database maintained by CMS for public reporting for the following performance measures:

  • Acute Myocardial Infarction Management
  • Heart Failure management
  • Surgical Infection Prevention Management

We have consistently scored greater than 95% for all relevant Acute Myocardial Infarction and Heart Failure measures; and scored greater than 92% for all Surgical Infection Prevention measures. Thus we have consistently achieved a rank in the top 10-20% of all hospitals nationwide and have achieved the status of “Top Hospital” for a number of quality measures.

Deborah’s Results

HealthStream Research

Deborah Heart and Lung Center has commissioned HealthStream Research to conduct its inpatient and outpatient satisfaction tracking survey. HealthStream Research is a national survey research company solely dedicated to healthcare; they have over 200 clients nationwide. The patient satisfaction surveys are conducted by telephone to insure a higher response rate and better reliability. Patients respond according to a 5-point scale allowing for a more optimal distribution of responses. HealthStream Research surveys patients the month following their visit to Deborah Heart and Lung Center. Deborah results are compared to HealthStream Research’s national database and rankings are given.