The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
North Shore University Hospital
DBA: North Shore University Hospital
Org ID: 2091
300 Community Drive
Manhasset, NY  11030
(516)562-4039
northshorelij.com


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Hospital
Accredited 2/1/2014 1/31/2014   1/31/2014  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Advanced Palliative Care
Certification 1/16/2014  1/15/2014  1/15/2014 
Inpatient Diabetes
Certification 5/15/2014  5/14/2014  5/14/2014 
Primary Stroke Center
Certification 6/21/2012  6/20/2012  6/20/2012 





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  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
This measure is not applicable for this organization.
Not displayed
  Footnote Key
1. The measure or measure set was not reported.
2. The measure set does not have an overall result.
3. The number is not enough for comparison purposes.
4. The measure meets the Privacy Disclosure Threshold rule.
5. The organization scored above 90% but was below most other organizations.
6. The measure results are not statistically valid.
7. The measure results are based on a sample of patients.
8. The number of months with measure data is below the reporting requirement.
9. The measure results are temporarily suppressed pending resubmission of updated data.
10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
11. There were no eligible patients that met the denominator criteria.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Hospital
2014 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Apr  2013 -
Mar  2014
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
Pneumonia Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Stroke Care See Detail
Not displayed.
8
Not displayed.
8
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Blood Vessel Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Colon/Large Intestine Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Coronary Artery Bypass Graft
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hip Joint Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Knee Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Open Heart Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
 
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
Ambulatory Dental Center
400 Community Drive
Manhasset, NY  11030
    Services:
    • Outpatient Clinics (Outpatient)
    Bethpage Medical Walk-In Center
    DBA:  Hospital Extension Clinic
    4300 Hempstead Turnpike
    Bethpage, NY  11714
      Services:
      • Urgent Care (Outpatient)
      Center for Advanced Medicine
      450 Lakeville Road
      New Hyde Park, NY  11042
        Services:
        • Outpatient Clinics (Outpatient)
        Irving Goldman Family Care Center
        865 Northern Boulevard
        Great Neck, NY  11020
          Services:
          • Outpatient Clinics (Outpatient)
          Julia & Israel Waldbaum Dialysis Center / Sleep Center
          100 Community Drive
          Great Neck, NY  11021
            Services:
            • Administration of Blood Product (Outpatient)
            • Administration of High Risk Medications (Outpatient)
            • Dialysis (Outpatient)
            • Outpatient Clinics (Outpatient)
            North Shore LIJ Imaging at Great South Bay
            620 Main Street
            Islip, NY  11751
              Services:
              • Outpatient Clinics (Outpatient)
              North Shore LIJ Imaging at Syosset
              DBA:  Imaging
              100 Lafayette Drive, Syosset New York
              Syosset, NY  11791
                Services:
                • Outpatient Clinics (Outpatient)
                North Shore University Hospital  *
                300 Community Drive
                Manhasset, NY  11030
                Joint Commission Advanced Certification Programs:
                • Advanced Palliative Care
                • Inpatient Diabetes
                • Primary Stroke Center
                  Services:
                  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult)
                  • Cardiac Catheterization Lab (Surgical Services)
                  • Cardiac Surgery (Surgical Services)
                  • Cardiothoracic Surgery (Surgical Services)
                  • Cardiovascular Unit (Inpatient)
                  • Coronary Care Unit (Inpatient)
                  • CT Scanner (Imaging/Diagnostic Services)
                  • Dialysis Unit (Inpatient)
                  • Ear/Nose/Throat Surgery (Surgical Services)
                  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                  • Gastroenterology (Surgical Services)
                  • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                  • Gynecological Surgery (Surgical Services)
                  • Gynecology (Inpatient)
                  • Hematology/Oncology Unit (Inpatient)
                  • Inpatient Unit (Inpatient)
                  • Interventional Radiology (Imaging/Diagnostic Services)
                  • Labor & Delivery (Inpatient)
                  • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                  • Medical /Surgical Unit (Inpatient)
                  • Medical ICU (Intensive Care Unit)
                  • Neuro/Spine ICU (Intensive Care Unit)
                  • Neuro/Spine Unit (Inpatient)
                  • Neurosurgery (Surgical Services)
                  • Normal Newborn Nursery (Inpatient)
                  • Nuclear Medicine (Imaging/Diagnostic Services)
                  • Ophthalmology (Surgical Services)
                  • Orthopedic Surgery (Surgical Services)
                  • Orthopedic/Spine Unit (Inpatient)
                  • Outpatient Clinics (Outpatient)
                  • Plastic Surgery (Surgical Services)
                  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                  • Post Anesthesia Care Unit (PACU) (Inpatient)
                  • Radiation Oncology (Imaging/Diagnostic Services)
                  • Sleep Laboratory (Sleep Laboratory)
                  • Surgical ICU (Intensive Care Unit)
                  • Surgical Unit (Inpatient)
                  • Teleradiology (Imaging/Diagnostic Services)
                  • Thoracic Surgery (Surgical Services)
                  • Transplant Surgery (Surgical Services)
                  • Ultrasound (Imaging/Diagnostic Services)
                  • Urology (Surgical Services)
                  • Vascular Surgery (Surgical Services)
                  NSUH Extension Clinic Imaging Center
                  611 Northern Blvd.
                  Great Neck, NY  11021
                    Services:
                    • Outpatient Clinics (Outpatient)
                    NSUH Imaging Center
                    711 Stewart Avenue
                    Garden City, NY  11530
                      Services:
                      • Outpatient Clinics (Outpatient)
                      Syosset Hospital
                      DBA:  Hospital
                      221 Jericho Turnpike
                      Syosset, NY  11791
                      Joint Commission Advanced Certification Programs:
                      • Inpatient Diabetes
                        Services:
                        • CT Scanner (Imaging/Diagnostic Services)
                        • Ear/Nose/Throat Surgery (Surgical Services)
                        • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                        • Gastroenterology (Surgical Services)
                        • Gynecological Surgery (Surgical Services)
                        • Inpatient Unit (Inpatient)
                        • Interventional Radiology (Imaging/Diagnostic Services)
                        • Medical /Surgical Unit (Inpatient)
                        • Medical ICU (Intensive Care Unit)
                        • Neurosurgery (Surgical Services)
                        • Nuclear Medicine (Imaging/Diagnostic Services)
                        • Ophthalmology (Surgical Services)
                        • Orthopedic Surgery (Surgical Services)
                        • Plastic Surgery (Surgical Services)
                        • Teleradiology (Imaging/Diagnostic Services)
                        • Thoracic Surgery (Surgical Services)
                        • Ultrasound (Imaging/Diagnostic Services)
                        • Urology (Surgical Services)
                        • Vascular Surgery (Surgical Services)
                        The Center for Wound Care/Hyperbaric Facility
                        1999 Marcus Avenue
                        New Hyde Park, NY  11042
                          Services:
                          • Outpatient Clinics (Outpatient)

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