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 Legacy's accreditation

Our hospitals and hospice services are regularly reviewed and accredited by The Joint Commission. Specific accreditation awards across Legacy include:

  • Baby Friendly: Legacy Health has been recognized for its breastfeeding support at all our birth centers.
  • Breast health: Our Breast Health Centers have earned these national accreditations:
    • Breast Center of Excellence designation by National Accreditation Program for Breast Centers (NAPBC) (administered by American College of Surgeons)
    • Network Cancer accreditation by American College of Surgeons; plus a quality award, a distinction earned by just 5 percent of accredited systems nationwide
    • Breast Imaging Centers of Excellence, American College of Radiologist
    • Mammography services at Legacy Mount Hood Medical Center and Legacy Medical Group-St. Helens have also earned the Breast Center of Excellence designation by NAPBC (administered by American College of   Surgeons).
  • CancerLegacy Cancer Institute is accredited by The American College of Surgeons. In 2016, the Legacy Cancer Institute won the Outstanding Achievement Award by the Commission on Cancer (CoC) of the American College of Surgeons (ACS) for the third accreditation survey cycle in a row – the first provider in Oregon to do so.
  • Continuing medical education: Oregon Medical Association to provide AMA PRA Category 1 Credits™ activities for physicians.
  • Diabetes education: Legacy's diabetes education programs have been recognized by the American Diabetes Association for Quality Self-Management Education. 
  • Epic: Legacy is the first organization in the world to achieve the 2017 Connect Accreditation from Epic. The award recognizes Legacy’s programs to successfully extend Legacy Epic to affiliated practices and hospitals. Wisconsin-based Epic Systems is a leading provider of electronic health records (EHR) systems. Legacy first began deploying the Epic EHR to our hospitals in 2010.
  • Imaging: The Oregon Department of Health/Radiation Protection Services and the Washington State Department of Health, Division of Radiation Protection routinely inspect Imaging Services, including Radiology, Nuclear Medicine and Radiation Oncology.
  • Laboratories: Our laboratories are accredited by the College of American Pathologists (CAP). Legacy Laboratory Services is also the fourth clinical lab in the U.S. to achieve an international quality certification across an entire lab organization.
  • Mammography: Legacy mammography services are inspected annually to assure compliance with the Mammography Quality Standards Act (MQSA). 
  • Medicare inspections are held for our pharmacies and behavioral health services. 
  • Pastoral care: Our Clinical Pastoral Education program is reviewed by the Association for Clinical Pastoral Education.
  • Pharmacy services and blood bank: The Food & Drug Administration inspects our pharmacy services and blood bank. The blood bank also receives an annual inspection from the American Association of Blood Banks. Pharmacy services also undergoes an annual inspection by the Oregon and Washington Boards of Pharmacy.
  • Residency programs: Our residency programs are accredited by the Accreditation Council for Graduate Medical Education, The Council for Podiatric Medical Education and the ADA Commission on Dental Accreditation. The Pharmacy Residency Program is accredited by the American Society of Health System Pharmacists.
  • Sleep programs: Our sleep services are accredited by the American Academy of Sleep Medicine.
  • Stroke: The stroke programs at Legacy Good Samaritan, Legacy Meridian Park, and Legacy Salmon Creek Medical Centers have been awarded Certificates of Distinction as Primary Stroke Centers by The Joint Commission. The Legacy Stroke Program is also accredited by the Commission on Accreditation for Rehabilitation Facilities (CARF).

Accreditation of individual services and programs

  • The Cardiac Rehabilitation Program at Good Samaritan Medical Center is certified by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).
  • The Children's Cancer and Blood Disorders Program is a member of and receives oversight from the Children's Oncology Group (COG).
  • Legacy Autologous Stem Cell Transplant Program is accredited by the Foundation for Accreditation of Cellular Therapy (FACT).
  • Legacy Cytogenetics Laboratory is certified by the Children's Oncology Group (COG).
  • Legacy Emanuel Medical Center Level I Trauma Center is designated by the Department of Human Services for Oregon and accredited by The American College of Surgeons. 
  • In April of 2016, a survey by the The College of American Pathologists found no deficiencies in a system-wide survey in most of the areas surveyed at Legacy Emanuel including General Lab, Microbiology, Coagulation, Urinalysis, Cytology, Chemistry and Toxicology, Respiratory Care and Point of Care Testing. 
  • Legacy Good Samaritan Sleep Durable Medical Equipment department is accredited by The Joint Commission.
  • The stroke program at Legacy Emanuel Medical Center has been accredited as a Comprehensive Stroke Program.
  • Legacy Good Samaritan Weight and Diabetes Management Institute and Oregon Weight Loss Surgery, the physician practice that works with the institute, are accredited by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence.
  • Legacy Institute for Surgical Education and Innovation (LISEI) is  accredited by The American College of Surgeons as a Level I Educational Institute.
  • Legacy Laboratory Services realized a significant accomplishment with the announcement that they had achieved ISO 15189:2012 accreditation for the Legacy Central Laboratory, Feb. 1, 2015.
  • Legacy Oregon Burn Center is accredited by the American Burn Association and The American College of Surgeons.
  • Legacy Pediatric Rehabilitation Program is accredited by the Commission on Accreditation for Rehabilitation Facilities (CARF). 
  • Legacy Research Institute maintains an assurance with the Department of Health's Office of Human Subject Protections to conduct clinical studies, and with the National Institute of Health's Office of Laboratory Animal Welfare to conduct basic research. The human subjects program is periodically audited by the Food and Drug Administration. Legacy maintains a license to conduct animal research with the U.S. Department of Agriculture, which conducts yearly inspections, and is accredited by the Association for Accreditation & Assessment of Laboratory Animal Care.
  • Legacy Transplant Services is a member of and receives oversight from the United Network for Organ Sharing (UNOS).
  • In June 2015, the Legacy Tumor Bank received accreditation from the College of American Pathologists (CAP) based on results of an on-site inspection. The CAP Biorepository Accreditation process, a three-year accreditation cycle, includes on-site inspection, desk review, and optional education modules and gap assessment.

  • Life Flight Network, LLC is accredited by the Commission on Air Medical Transport Programs (CAMPTS).