Montefiore St. Luke’s Cornwall is committed to quality, and is accredited by several organizations that set health care standards and monitor performance.

Quality Recognition

General Surgery

undefinedGeneral Surgery at Montefiore St. Luke’s Cornwall (MSLC) is among the top 10% in the nation—as measured by volume-weighted performance—according to this year’s evaluation from Healthgrades, the leading online resource for comprehensive information about physicians and hospitals. Every year, Healthgrades evaluates hospital performance at nearly 4,500 hospitals nationwide for 34 of the most common inpatient procedures and conditions.

As a direct result of the hospital’s relationship with the Montefiore Health System, SLCH recently re-introduced a thoracic surgery program, expanding the number of procedures and conditions able to be treated in the local community.

This achievement is part of findings released by Healthgrades and is featured in their 2018 Report to the Nation, which includes detailed study methodology and can be found at The new report demonstrates how clinical performance continues to differ dramatically between hospitals regionally and nationally.

This variation in care has a significant impact on health outcomes. For example, from 2014-2016, patients treated at hospitals receiving the General Surgery Specialty Excellence Award have, on average, had a 25.0% lower risk of experiencing a complication or dying while in the hospital than if they were treated in hospitals that did not receive the award.

Healthgrades® Five Star Recipient

Healthgrades 2018 Award LogoHealthgrades® has recognized Montefiore St. Luke’s Cornwall for its high quality patient care. We have received this recognition in Natural Childbirth for six consecutive years (2015-2020). 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. MSLC has also received a 5-star rating in C-Section Delivery in 2020.

Blue Distinction Center for Knee and Hip Replacement

undefinedMontefiore St. Luke’s Cornwall's 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 Montefiore St. Luke’s Cornwall as a Blue Distinction Center for Knee and Hip Replacement, part of the Blue Distinction Specialty Care program. The MSLC 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,MSLC demonstrates expertise in total knee and total hip replacement surgeries, resulting in fewer patient complications and hospital readmissions.

With this designation, MSLC'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.

Blue Distinction Center for Maternity Care

undefinedMontefiore St. Luke’s Cornwall'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 Montefiore St. Luke’s Cornwall as a Blue Distinction Center for Maternity Care. With this designation, MSLC 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.

Blue Distinction Center for Bariatric surgery

Montefiore St. Luke’s Cornwall's Newburgh campus is designated as a Blue Distinction Center for Bariatric Surgery by Empire Blue Cross Blue Shield, an independent licensee of Blue Cross Blue Shield Association. Our Bariatric Surgery Center offers Laparoscopic Sleeve Gastrectomy, Laparoscopic Gastric Bypass, and Laparoscopic Band Removal and Revision procedures performed by a highly trained, qualified team of bariatric surgeons on the staff of MSLC. As a Blue Distinction Center for Bariatric surgery, Montefiore St. Luke's Cornwall is a nationally designated healthcare facility recognized for its expertise in delivering Bariatric specialty care and meeting nationally established quality measures. Our Bariatric Surgery program is also accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program ( MBSAQIP) as a Comprehensive Center.

A great place to work

Montefiore St. Luke’s Cornwall (MSLC) was certified as a great workplace for the third year in a row by the independent analysts at Great Place to WorkTM. MSLC has earned this credential based on extensive ratings provided by its employees in anonymous surveys. MSLC is one of only thirteen hospitals in the nation to be recognized as a Great Place to Work, and the organization joins the likes of St. Jude’s Children’s Hospital.


undefinedMontefiore St. Luke’s Cornwall'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).

MSLC 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. MSLC’s accredited center offers preoperative and postoperative care designed specifically for their bariatric patients.

To earn the MBSAQIP designation, MSLC met essential criteria for staffing, training, facility, infrastructure and protocols for care, ensuring its ability to support patients with severe obesity. MSLC’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. MSLC received outstanding remarks from its survey earlier this year, which included acknowledgment of the team’s leadership and excellent clinical outcomes.

Level III Trauma Center

undefinedThe trauma center at Montefiore St. Luke’s Cornwall 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 MSLC Trauma Program officially began in May 2014, allowing the hospital to operate provisionally as an Area Trauma Center. Since that time, the MSLC 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, MSLC had its trauma verification survey conducted by the American College of Surgeons Committee on Trauma. MSLC 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.

MSLC is proud to partner with Surgical Affiliates Management Group (SAMGI) in the management of MSLC'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 MSLC 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

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

MSLC 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.

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

undefinedWe are pleased to announce that in November 2014, The Joint Commission recognized Montefiore St. Luke’s Cornwall as a 2013 Top Performer on Key Quality Measures®. Montefiore St. Luke’s Cornwall 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 Montefiore St. Luke’s Cornwall,” said Robert S. Ross, MSLC 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

American Stroke Association Recognition

undefinedMontefiore St. Luke’s Cornwall (MSLC) has received the American Heart Association/American Stroke Association’s Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award for the 11th consecutive year. The award recognizes the hospital’s commitment to ensuring stroke patients receive the most appropriate treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence.

undefinedMSLC 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 measures include evaluation of the proper use of medications and other stroke treatments aligned with the most up-to-date, evidence-based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients. Before discharge, patients should also receive education on managing their health, get a follow-up visit scheduled, as well as other care transition interventions.

undefinedAdditionally, MSLC received the Target: StrokeSM Honor Roll Elite Plus award. To qualify for this recognition, 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.

undefined The Montefiore St. Luke’s Cornwall Hospital Cardiovascular Service Line provides an individualized and comprehensive approach to identification of cardiac risk factors and quick assessment of symptoms. State-of-the-art cardiac diagnostic equipment allows the staff to quickly obtain the necessary information to diagnose heart problems and determine the best possible plan of care.

According to the American Heart Association/American Stroke Association, stroke is the No. 5 cause of death and a leading cause of adult disability in the United States. On average, someone in the U.S. suffers a stroke every 40 seconds and nearly 795,000 people suffer a new or recurrent stroke each year.

2020 Mission: Lifeline Gold Receiving Award

Montefiore St. Luke’s Cornwall (MSLC) has received the Mission: Lifeline®Gold Receiving Quality Achievement Award for implementing specific quality improvement measures outlined by the American Heart Association for the treatment of patients who suffer severe heart attacks.

The hospital earned the Silver Award in 2019, and the Bronze in 2018, as these were the highest achievement possible as a result of the metrics and submissions required.

2019 Health Care's Most Wired

undefinedMontefiore St. Luke’s Cornwall Hospital (MSLC) 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. MSLC 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 is published annually by Hospitals & Health Networks (H&HN). The 2019 Most Wired® survey and benchmarking study is a leading industry barometer measuring information technology (IT) use and adoption among hospitals nationwide.

Aetna Institute of Quality® (IOQ) for Cardiac Care

undefinedMontefiore St. Luke’s Cornwall has been designated as an Institute of Quality® for Cardiac Medical Intervention by Aetna. MSLC 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.

Undersea and Hyperbaric Medical Society

undefinedThe Montefiore 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

undefinedMSLC 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.

Commission on Cancer Accreditation by the American College of Surgeons (CoC)

undefined The oncology program at MSLC 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."

American Diabetes Association

undefinedThe diabetes self-management program at Montefiore St. Luke’s Cornwall (MSLC) 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).

College of American Pathology (CAP)

undefinedThe 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 re-certification required every two years.

American Academy of Sleep Medicine

undefinedThe Montefiore St. Luke’s Cornwall Center for Sleep Medicine locations in Cornwall and Fishkill have 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 MSLC Center for Sleep Medicine is a facility that not only provides quality diagnostic services but also effective treatment methods for its patients.

American College of Radiology (ACR)

undefinedMSLC 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 (AACVPR)

undefinedThe AACVPR has awarded MSLC's Cardiac Rehabilitation Program re-certification 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.


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 MSLC, 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 contact the Joint Commission via the following methods:

  1. Visit on the web at , using the “Report a Patient Safety Event” link in the “Action Center” on the home page of the website
  2. By fax to 630-792-5636
  3. By mail to The Office of Quality and Patient Safety (OQPS), The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181

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