Junaid H. Khan, M.D.
- Congratulations to the entire Medical Staff for a successful launch of the Sepsis Initiative. Dr. Kris Kury is the lead of the Initiative.
- You will notice a reduction in the amount of overhead pages. If you have not provided your preferred method of contact to the operator, please do so via the Medical Staff Office.
- Inpatient translation services are available via the Patient Relations/Risk Management Office with advance notice required for certain languages. This is an adjunct to the telephone translation services currently in use at the medical center.
- The recent unplanned EPIC downtime identified several significant opportunities for EHR improvement at the system and at the local level. We are working to implement some improvements in our systems via the EHR Committee. If you have any questions or suggestions, please reach out to Dr. Gunawardane.
- Suspension for incomplete medical record queries are under consideration. We have not implemented these at Summit yet, but I would strongly encourage you to respond promptly to these queries as they aid in correctly risk stratifying the patients in terms of quality metrics as well as billing. This is a relatively new work flow for some physicians. Alisa Stinn from Health Information Services (HIM) has agreed to work with physicians to streamline the process.
- If you are a member of the Active Staff, we look forward to seeing you at the next Closed Active Staff Meeting on Nov. 12, 2015, where we will be selecting two members for the nominating committee for Medical Staff Officers’ two year terms starting Feb. 1, 2016. (Please note this meeting is for Active Staff only. If you are unsure of your staff category, please call the Medical Staff Office at 510-869-6565.)
- Dr. Rick Trautner has been ratified as the new Chief of the newly approved Psychiatry Service at Summit.
- The Palliative Care Service presented their first report at the Medical Staff Performance Improvement Committee last month.
- Read below about August recess of Grand Rounds and Pulmonary Conferences.
By Junaid Khan, M.D.
Date: July 28, 2015
To: All Physicians, Clinicians and Volunteers
From: Ursula Boynton, Administrative Medical Director, Alta Bates Summit Medical Center
Re: August Recess of Summit Grand Rounds and Pulmonary Conference
For the month of August, the following educational activities at the Summit Campus will take a recess:
- Summit Grand Rounds (Thursdays at 12:15pm)
- Pulmonary Conference (2nd and 4th Tuesdays at 12:15pm)
Please note that the physician’s lunch will continue to be served in the Fir Conference rooms every Thursday from 11:00-1:30pm during this time.
After this break, the next Summit Grand Rounds will occur on Thursday September 3rd at 12:15pm and the next Pulmonary Conference is planned for Tuesday September 8th at 12:15pm.
The following educational activities will not be affected by this recess and will continue on as scheduled for August:
- ABSMC General Tumor Board (Mondays at noon)
- Hematology Pre-Treatment Conference (1st and 3rd Tuesday at 8:00am)
- Breast Tumor Board and Pre-Treatment Conference (Wednesdays at noon)
- Lung Tumor Board (4th Thursday at 4:30pm)
- GI Tumor Board (3rd Thursday at 4:30pm)
In the meantime, feel free to contact Robert Romero, CME Coordinator, at 510-204-2423, or Najia Jamjoum, Tumor Board Coordinator, at 510-204-2160 with any questions.
Thank you and enjoy your summer!
By Ursula Boynton, MD
Please welcome the physicians who joined our staff in July:
Satya Chelamkuri, M.D.
1510 4th St. Ste. 1
Berkeley, CA. 94710-2302
Eric Davies, M.D.
365 Hawthorne Ave. Ste. 101
Oakland, CA. 94609-3115
John Lee, M.D.
501 S. Shore Ctr. W., Ste. 103F
Alameda, CA 94501-5762
Radhika Madhavan, M.D.
Obstetrics & Gynecology
2500 Milvia St.
Berkeley, CA 94704-2636
Judith Stanton, M.D.
2450 Ashby Ave. , Rm. 505
Berkeley, CA. 94705
Ami Yamamoto, M.D.
3470 Mt. Diablo Blvd. A220
Lafayette, CA. 94549-1069
By Medical Staff Services
Junaid H. Khan, M.D.
- Congratulations to the entire Medical Staff for a very successful Sepsis Mortality Reduction Program Go Live under the leadership of Dr. Kris Kury.
- EMIM Champions have been on campus to help non-radiologists with their work flows. If you have questions, please reach out to our EHR Liaison Patty Fitzgibbons.
- Notices to Medical Staff have been sent out to query their preferred contact method as efforts are underway to minimize the number of overhead pages. The goal is to improve our patient experience.
- Summit had a great TJC Stroke Survey under the leadership of Drs. Jeff Chen and Brian Richardson. The Stroke Program received a two-year certification. The Total Joint Survey, under the leadership of Dr. David Chang, and the survey of the new tower are still pending.
- OPTIME for Epic is still scheduled to launch in the operating room Oct. 1, 2015, under the leadership Dr. Jill Kacher-Cobb.
- The Medical Staff sent a letter of appreciation to Mayor Libby Schaff for her efforts in helping us clean up the 27th Street underpass and the area by Mosswood Park. We have thanked her and asked her to continue her efforts as this will be a long-term process.
- The Case Management Program will be undergoing a complete evaluation by Price-Waterhouse-Coopers. Medical Staff leaders will be asked for input.
- Nursing staffing remains a challenge, but incremental improvements have been noted with extensive recruitment programs for new grads.
- Please join me in welcoming Veronica Bargas, RN, as our new permanent ICU nurse manager.
- Thank you to the physicians who participated in the Volunteer Shadowing Program under the leadership of Justin Lee, MD; Hussain Gilani, MD; and Christine Lee, MD. The initial evaluations were very positive from the volunteers and the physicians. We will do some fine tuning and continue the program.
- Read about Interval Notes. (Click on bold text.)
- Learn about Revised Medical Staff Rules & Regulations and Bylaws. (Click on bold text.)
By Junaid Khan, M.D.
Read More about From the President, July 2015
Please welcome physicians who joined our staff in June.
Eric Arnold, M.D.
2001 Dwight Way, Ste. 4190
Berkeley, CA. 94704-2608
Shraddha Prakash, M.D.
350 Hawthorne Ave. Ste. 320
Oakland, CA. 94609
Leslie Ross, PhD
2001 Dwight Way. 5N
Berkeley, CA 94704-2608
Jamie Van Hoften, M.D.
3000 Colby St. Ste. 205
Berkeley, CA 94705
Junaid H. Khan, M.D.
- Sepsis Task force initiative to lower mortality will start June 16. Code sepsis and Sepsis Alerts will be going out. Dr Kris Kury is our champion and has done a great job communicating changes in protocols and order sets to initiate on this date. If you have further questions please reach out to Dr Kury.
- EMIM/Visage team will be reaching out to staff physicians (previously they were limiting their focus on radiologist work flow) to identify and facilitate improvement in work flows. June Bolger is the Sutter administrative contact and will be working with physicians at Summit.
- Special thanks to Dr. Jeff Chen for escorting Mayor Libby Schaff around our campus in May and to Dave Lawson, administrative director of support services, for coordinating with the city and Caltrans to address the aggressive panhandling on 27th Street and trash by Mosswood Park underpass. More work to still be done.
- Pro Transport services are available to facilitate patient discharges. If you identify a logistical challenge due to transportation, you can discuss this option with case management.
- Parking enforcement has started in the Summit garage. If you do not have a grey sticker on your car, you can get one from the medical staff office. Hybrid parking and other posted rules also will be enforced.
- Nursing staffing is overall better, but opportunities for improvement remain (particularly in the ICU). The next contract discussion with CNA will begin late this year.
- A new protocol for managing exposures to blood-borne pathogens is in place. No longer will you need to worry about charges for services or what lab tests are ordered. ABSMC’s managers and nursing (admin) supervisors have been trained on the streamlined process.
- New physician orientation will be held at 5:30 p.m. June 2 in the Bay View Conference Room for all physicians, PAs, and NPs who have joined the medical staff since January.
- E H R – For information on H&P interval notes and E H R enhancements, please see the physician liaison, Patty Fitzgibbons, 510-325-9618 or FitzgiP@Sutterhealth.org
Please welcome the physicians who joined our staff in May.
Golaun Odabaei, M.D.
2905 Telegraph Ave.
Berkeley, CA 94705-2017
Marisa Oishi, M.D.
350 Hawthorne Ave.
Oakland, CA 94609
Junaid H. Khan, M.D.
• I am testing a survey question. Please take a minute to click here, answer the question and then read the response.
• Please indulge me by watching this Cleveland Clinic video that was presented at an Improving the Patient Experience conference I attended.
• I would like to ask for your help in preventing patients from leaving the floors to go smoke out front. This is a patient safety issue as well as an esthetic issue. The official policy of the medical center is to offer counseling and nicotine patches, and not give passes. If a patient insists on leaving, then they should be discharged AMA.
• Chuck Prosper has outlined a Master Facility Plan proposal to be submitted to Sutter to include enhancements in the Cardiac Cath Labs, creation of a Hybrid Operating Room and in-facility MRI with a rough completion target date of late 2018.
• We will have four Joint Commission surveys in the next few months: Knee, Hip, Stroke and follow up to the new tower. A key item identified as a focus will be “updated H&Ps” (i.e. interval notes).
• The hospital remains at a very high census. Physicians can help by identifying patients for discharge early in the day. The official closure of Doctors Medical Center will continue to have an impact on visits to our ED.
• Dr. Martin Garcia has agreed to represent Summit, along with Drs. Charu Puri and Michael Kim, at the system level EHR work group. Dr. Garcia has been doing a fantastic job on the RVOT Committee coordinating with local stake holders with respect to order set changes in EPIC.
• We are working with our physician Well Being Committee to create a task force to consider an approach to assessing the impact of aging on all practitioners’ capacity to perform requested privileges. This item has been working its way through CMA, with a draft proposal being discussed for approval at the system level. More details to follow.
• Special thanks to Administration for enhancing the Hospitalist work space/lounge.
By Junaid Khan, M.D.
In January, the ABSMC Research and Education Institute (REDI) began revamping some of its educational programs to enhance the curriculum and increase physician participation.
The first program improvement is the Summit Medical Staff Grand Rounds, which meets every Thursday from 12:15-1:15 p.m. in the Fir conference rooms. Thanks to the collaborative efforts of the Summit Medical Staff president and Medical Staff Services, Food and Nutrition Services and EVS, our CEO, senior administrative staff and the Summit CME Committee, we now have a robust program offering weekly educational lectures on a wide variety of medical topics with buffet lunch provided.
To enhance the Tumor Board program and to remain in compliance with Commission On Cancer requirements, the Ashby and Summit General Tumor Boards have combined. All cases will be presented at the merged General Tumor Board that occurs weekly on Mondays at noon in the Family Resource Conference Room at the Summit Campus South Pavilion.
This joint meeting is open to all physicians and will be broadcast live via WebEx for those who wish to take part and earn CME credit virtually. The first joint General Tumor Board is scheduled to convene Monday, May 4 at noon. To submit cases for presentation, to be added to the email distribution list or to obtain a WebEx invite, please contact Najia Jamjoum, the tumor board coordinator, at 510-204-2160 or firstname.lastname@example.org.
For questions about the Commission On Cancer requirements or about Alta Bates Summit Comprehensive Cancer Center programs, please contact Kimberly Christensen at email@example.com.
Other continuing medical education activities scheduled for enhancement include Psychiatry Grand Rounds that convenes at the Herrick Campus on Monday’s (first, second and third Mondays of the month) at noon in the Maffly Auditorium. This CME activity runs on an academic calendar from October through May and is open to all medical staff.
Additionally, the Pulmonary Conference that takes place at the Summit Campus on Tuesdays in the Fir conference rooms at noon has been reduced in frequency from weekly to biweekly beginning Tuesday, May 12. This schedule change will be for the short term until further notice. To submit cases for presentation at the Pulmonary Conference or to be added to the email distribution list, please contact Najia Jamjoum at 510-204-2160 or firstname.lastname@example.org.
Future educational activities include the 28th Annual East Bay HIV Update Conference scheduled for Friday, May 29 at Samuel Merritt University. Featured faculty speakers include Jeff Burack, M.D.; Steve O’Brien, M.D.; and Anthony Jones, M.D.; as well as a host of highly qualified physicians and health care professionals working in the East Bay. This activity is open to primary care and HIV doctors, nurses, pharmacists, case managers, program coordinators and client advocates.
Also planned is the 10th Annual Goggio Cardiovascular Conference scheduled for Wednesday, Oct. 28 at Samuel Merritt University, featuring staff speakers Russell Stanten, M.D.; Eric Johnson, M.D.; Jack Edelen, M.D.; Kristina Kury, M.D.; Michael Lee, M.D.; and Junaid Kahn, M.D.
For more information on these upcoming conferences, please contact me at 510-204-2423 or email@example.com.
By Robert Romero
ABSMC CME Coordinator
#1 (Inpatient Overlay):
An inpatient overlay is created when a patient has been registered incorrectly under another patient’s Epic record or when care providers inadvertently chart on the wrong patient record.
- When discovery of an overlay has been identified IMMEDIATELY CALL the EHR Service Desk (888-888-6044) while the patient is still in-house. DO NOT EMAIL.
- Let them know you have a patient currently in-house who has been registered incorrectly. Let the service desk know the following, “This is a patient safety issue. Please page the Chart Correction Team (CCT)”.
- The EHR Service Desk will create a High Priority INC (Remedy Incident Ticket) for the Chart Correction Team CCT to be paged out.
#2 (Cutting and Pasting):
The Joint Commission has received reports to the Sentinel Event Database noting documentation errors and other problems with the data integrity of the clinical record. Several sentinel events leading to patient harm report the Cute and Paste Function (CPF) as the specific root cause. Although it is difficult to determine how often CPF leads to patient harm due to the challenge of accurately identifying and tracking this information, as the adoption of EHRs continues to increase, the potential for patient harm due to the copy and paste function also increases. Examples of harm included outdated weight information used for dose calculation of chemotherapeutic agents, and lengthy progress notes that prevent timely and efficient communication.
The Joint Commission Sites Several Risk Factors:
- Copying an pasting inaccurate or outdated information
- Redundant information in the EHR which makes it difficult to identify the current information
- Inability to identify the author or intent of the documentation
- Inability to identify when the documentation was first created
- Propagation of false information
- Inconsistent and lengthy progress notes
Safety Actions to Consider:
- Be aware of the risks
- Work collaboratively with health care providers and organization leadership
- Develop training and education related to the CPF
- Maintain robust quality review processes
- Identify opportunities for improvement
- Develop policy and procedures addressing the proper use of the CPF
#3 (Out of Office / Vacation Procedure)
Q: What do I do when I am going on vacation or going off service for anticipated or unanticipated absences?
A: Physicians, or someone on his/her behalf, shall notify the Health Information Management Department that you are going on vacation or off service. HIM will place your records on an “OUT OF OFFICE” hold while you are out. This places your deficient records and delinquent days on hold. Upon return, the physician will be allotted one calendar day to complete the records before suspension of privileges for delinquent records with publication of the next suspension list.
#4 (Deficiencies & Content Requirement for Documentation)
- Effective Sept 2014 – Health Information Management at Shared Services obtained approval from the Chiefs of Staff to analyze and suspend for missing content in H&P, Operative Reports, Post Op Progress Notes and Discharge Summary. This information was not sent back to the Local Affiliate in a timely manner which has led to frustration and a decrease in physician satisfaction.
- 1st Quarter 2015 – Shared Services and Health Information Management at the Local Affiliate worked to implement this change. This is a Sutter wide initiative and we are just now experiencing the full impact at ABSMC.
- Physicians are now being asked consistently to complete missing elements by both Shared Service and your Local HIM Department.
- Deficiencies appear as a Document/Dictate in your in-basket. The analyst will be placing a message in the comment box if you are missing a required element. Please make sure you are reading all messages from the analyst.
- Effective May 2015, Shared Services and Health Information Management at the Local Affiliate will start including deficiencies for missing Content and Pended Incomplete Notes in our suspension process.
- Review the “Content Requirements for Documentation” in next article. (Click on table in article below to enlarge text.) This crosswalk includes all Regulatory (TJC, Title 22, CMS) and our Medical Staff Rules and Regulations regarding the content of your Discharge Summary, H&P, Operative Reports, Immediate Post Op Progress Note and Verbal Orders.
- Review your templates and or smart phrases to ensure they include all content requirements. Work with our Physician Liaison if you need assistance updating your templates to include all content requirements.
- Top missing content elements:
- EBL and Specimen/Tissue Removed. These elements must be present in both Operative Report and the Immediate Post Op Progress Note. If there was no blood loss or no specimens removed, you would state “none.”
- Discharge Summary – These elements must be present on your Discharge Summary.
- Discharge or Final Diagnosis
- Dates of Admission and Discharge
- Condition on discharge
- See Crosswalk for all content requirements
- Pended Incomplete Notes: Please remember to complete, sign and or delete all pended notes. These are counted as a deficiency and were included in our suspension processing effective May 1, 2015.
By Alisa Stinn, RHIT
Client Location Lead, Health Information Management