North Shore University Hospital Medical Staff Society Inc

What it reported doing in 2025

The north shore university hospital medical staff society ("staff society") consists of all medical doctors who are on the medical staff of north shore university hospital at manhasset ("nsuh") by virtue of having hospital admitting privileges. The staff society seeks to promote and maintain the highest professional standards of the medical doctors who provide medical care to patients admitted to nsuh, to assist nsuh in assuring that the care provided to patients meet the highest clinical standards, and, with respect to such care, the hospital meets all clinically related certification requirements of external hospital credentialing authorities including the joint commission of accreditation of health organizations (jcaho) and official authorities such as the New York state department of health. The staff society also promotes the professional interest of its membership by providing timely information and advice to assist the members in performance of their medical practices. With respect to its mission to assist the hospital, the staff society, through its officers and members, serve on a variety of clinical boards and committees of the hospital including, but not limited to, the medical board, credentialing committee, medical record committee, performance improvement coordinating group, and pharmacy and therapeutics committee. By serving on the hospital's medical board, staff society officers help govern the medical staff, advise the board of trustees, the hospital's executive director, the health system ceo, chief medical officer and chief operating officer in matters relating to the welfare of the hospital and medical staff; make recommendations to the hospital's board of trustees for its approval, such as recommendations pertaining to: the structure of the medical staff, planning for clinical departments; the mechanism used to review credentials and to delineate individual clinical privileges; recommendations for delineated clinical privileges for each eligible individual; the participation of the medical staff in organizational performance-improvement activities; the mechanism by which medical staff membership and clinical privileges may be terminated or limited; the mechanism for fair-hearing procedure; requirements for the medical care and treatment of patients in the hospital and programs of education, research and preventative medicine conducted at the hospital. By participating on the hospital's credentials committee, staff society members review the completed applications of all applicants for membership on the medical staff who desire to practice at the hospital in compliance with the hospital's bylaws (including, but not limited to, interviewing such candidates as is it deems necessary or appropriate); make recommendations to the medical board on each such applicant regarding initial appointment, reappointment and delineation of clinical privileges, including specific consideration for recommendations of the chair of the clinical department in which the applicant requests privileges including recommendations by the chair for the revision of privileges in between reappointment periods; provide consulatative review of delineated privileges in new and evolving areas of medical practice. By participating on the hospital's medical record committee, staff society members help establish and coordinate a process involving the medical and ancillary departments that meet the requirements of the jcaho (and all other applicable accrediting and certifying boards and bodies) and the New York state department of health's review of medical records to assure appropriate clinical information is contained within the patient's chart; review medical records for timely completion, clinical pertinence, overall completeness and adequacy for quality assessment activities; advise and recommend policies for medical record maintenance; make recommendations to the medical board and to the performance improvement coordinating group whenever n

Financial Efficiency

• Mission deployment rate: 0%; rating input score 0
• Program expense ratio: Limited
• Fundraising efficiency: Limited

Transparency & Controls

• Consistency checks: 100%; rating input score 100; 63rd percentile among comparable filings
• Pay-setting controls: Limited
• Foreign activity oversight: Limited
• Grant itemization coverage: Limited
• Major donor itemization: Limited
• Related-party transparency: Limited

Accountability

• Independent voting board: 100%; rating input score 100; 64th percentile among comparable filings
• Governance controls: 1 of 7 controls in place; rating input score 14
  • Conflict-of-interest policy: Fail
  • Whistleblower policy: Fail
  • Document-retention policy: Fail
  • CEO compensation review process: NotApplicable
  • Other executive compensation review process: NotApplicable
  • Form 990 shared with the board: Fail
  • Board meeting minutes documented: Pass
  • Audit committee oversight: Missing
  • Independent financial-statement audit: Fail

Sustainability

• Operating margin: Limited
• Total-asset coverage ratio: Limited
• Liabilities to assets ratio: 0; rating input score 66; 66th percentile among comparable filings
• Officer compensation ratio: Limited

Growth

• Program expense growth: -29.9% per year; rating input score 0; 11th percentile among comparable filings
• Revenue growth: -13.9% per year; rating input score 0; 25th percentile among comparable filings
• Asset growth: 2.7% per year; rating input score 100; 52nd percentile among comparable filings