From the President, May 2015

Posted on May 4, 2015 in President's Message | 0 comments

Junaid H. Khan, M.D.

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.

ABSMC Continuing Medical Education (CME) Activities

Posted on May 4, 2015 in Announcements | 0 comments

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

For questions about the Commission On Cancer requirements or about Alta Bates Summit Comprehensive Cancer Center programs, please contact Kimberly Christensen at

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

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

By Robert Romero
ABSMC CME Coordinator

Health Information Management Updates and Announcements

Posted on May 4, 2015 in Health Information Management | 0 comments

#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.


  1. 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.
  2. 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.
  3. Top missing content elements:
  4. 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.”
  5. Discharge Summary – These elements must be present on your Discharge Summary.
    1. Discharge or Final Diagnosis
    2. Dates of Admission and Discharge
    3. Condition on discharge
    4. See Crosswalk for all content requirements
    5. 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

Content Requirements for Documentation

Posted on May 4, 2015 in Health Information Management | 0 comments

Click on Table to Enlarge Text.

HIM Content requirements_Page_1

Welcome New Physicians

Posted on May 4, 2015 in New Physicians | 0 comments

Please welcome the new physicians who joined our staff in April.

Kimberly Blumberg, M.D.
Diagnostic Radiology
2125 Oak Grove Rd. #200
Walnut Creek, CA. 94598

Daniel Paik, M.D.
Gynecology & Oncology
1455 Montego Suite 100
Walnut Creek, CA. 94598

Scott Peerenboom, DO
Internal Medicine
424 28th St.
Oakland, CA. 94609-3603

Santhi Raja, M.D.
Critical Care Medicine
350 Hawthorne Ave. #2346
Oakland, CA. 9409-3108

Denise Yun, M.D.
Internal Medicine
350 30th St.
Oakland, CA. 94609

From the President, April 2015

Posted on Mar 31, 2015 in President's Message | 0 comments

Junaid H. Khan, M.D.

Junaid H. Khan, M.D.

  • Please join me in thanking Administration for their generous gift to Operation Access on behalf of the Medical Staff for Doctor’s Day, March 30.
  • Physicians may use either set of elevators they wish. Administration is attempting to direct employees with equipment and food carts to use the employee elevators.
  • The response to the lunch services being moved to the Firs for Thursday Grand Rounds has been overwhelmingly positive and will now become permanent.  Special thanks to Dr. Ursi Boynton for her role in facilitating the process. There are a few requests to increase this program to other days to include other conferences. At this time we will be re-evaluating the food services options for physicians in total, including the utilization and options of the Physician Lounge on the ground floor, the Hospitalists’ work space on the second floor and other options. Please give us any suggestions. More details to follow.
  • Culture of Safety Survey will start April 1. Please take a moment to fill it out. 2014 showed a 60 percent improvement in the various metrics utilized by Leapfrog and the state to measure patient safety at Summit; a great collaborative effort between physicians, nursing and administration.
  • There will continue to be process improvement measures for EMIM with Dr. Eric Dovichi ( heading up the “SWAT” Team at Summit with Dr. Linda Gordon. Please reach out to them for specific questions.
  • EPIC optimization is still a key in individual physician work flow success. If you have not already done so, make an appointment with our Liaison, Patty Fitzgibbons (

By Junaid Khan, M.D.





2015 Culture of Safety Survey

Posted on Mar 31, 2015 in Announcements | 0 comments

Each spring, Sutter Health asks employees and hospital-based physicians to provide feedback on the Culture of Safety in our organization.   In 2014, we had outstanding patient safety achievements — including recognition from Leapfrog and HealthGrades — thanks to the dedication and commitment of our staff and physicians.

The medical center is hoping the work we’ve done relative to patient safety will be positively reflected by your teams again this year. On April 1, the hospital-based physicians will receive an email invitation to complete the Hospital Survey on Patient Safety Culture for Alta Bates Summit Medical Center. including instruction on how to access the survey.

The survey will be available online the first three weeks of April, is entirely confidential and takes about 10 minutes to complete.

We have received awards and accolades, in large part, because of the outstanding care our physicians provide to our patients. Our doctors are committed to the success of our medical  center and to ensuring our patients have a safe journey under our care. Each doctor is an excellent proponent of patient safety.

We have accomplished so much through our patient safety program and there is more to do. The medical center asks hospital-based physicians to participate in and reflect our achievements on the survey.  The input of our physicians will help us in this effort.

By Holly Colin
Risk Management


2014 Patient Safety Achievements

Posted on Mar 31, 2015 in Announcements | 0 comments

Alta Bates Summit Medical Center is committed to patient safety and to the goal that no patient will be harmed as a result of medical error. In 2014, we had remarkable patient safety achievements, thanks to the dedication and commitment of our staff and physicians:

  • Leapfrog (top hospital — AB campus, “A” hospital rating — both campuses).
  • HealthGrades (top distinguished hospital — Summit campus).
  • Reduced reported adverse events from 2013 to 2014 by 60 percent and pressure ulcers by 44 percent and was below the Sutter rate and the lowest in the East Bay region.
  • Falls rate on all campuses is on the decrease and is below the CALNOC benchmark (a California nursing quality organization).
  • Medication error rate continues to decline and has been on a downward trend since 2nd quarter, 2013.

ABSMC also received top recognition for quality and patient safety from:

  • U.S. News and World Report
  • American Heart Association
  • National Surgical Quality Improvement Project

We should all be proud of the tremendous work in quality and patient safety being done throughout the medical center. We celebrate our nurses, staff and physicians in their continuing efforts to provide safe and excellent care to our patients.

By Holly Colin
Risk Management


Sutter EHR Allows Clinician Access to Patient Medical Records From Other EPIC Users

Posted on Mar 31, 2015 in EHR Updates | 0 comments

A Sutter EHR module called Care Everywhere allows clinicians to electronically access patient medical records from other health care organizations that use EPIC.

Care Everywhere can provide access to records for shared patients who have received care at health care organizations that use Epic EHR, including Kaiser, UCSF, Stanford, UC Davis, John Muir, Washington Hospital, CVS Minute Clinics and UCSF Benioff Children’s Hospital Oakland.

“This is a powerful tool with value across the Sutter organization, from clinicians to support services staff,” says Louis Wu, M.D., medical director, East Bay Physicians Medical Group.

The Care Everywhere section displays in navigators for face-to-face encounters, which allows clerical or clinical staff to request electronic access to external medical records.

“Patients don’t have to remember whether they had the measles vaccine or whether they’re allergic to penicillin,” Wu says. “And we can get detailed information directly from lab reports and other technical documents.”

The Care Everywhere activity tab displays for patients who have had their Sutter Health record linked to their electronic record at one or more external organizations. This tab provides view access to downloaded information organized in a consistent and familiar manner.

“Support services staff can use Care Everywhere to follow up on care received by patients referred to Children’s or UCSF,” Wu adds.

Users can access Care Everywhere from active face-to-face patient encounters, including patient registration/arrival or treatment:

  • Queries may be performed by registration/reception staff and/or by clinical staff, however downloaded clinical information can only be viewed by clinical and Medical Records / Health Information Management staff.
  • External patient records may be linked and accessed via Care Everywhere only after the patient completes an Authorization for the Release of Health Information required by the source organization.
  • Authorization forms completed at Sutter Health on behalf of the source organization will be scanned and stored in the Sutter Health medical record and made available to the source organization upon request.

EPIC is working on Interoperability with other EHR providers.

By Liz Agnello
Writer and Publications Coordinator
Sutter Health East Bay Region

Welcome, New Physicians

Posted on Mar 31, 2015 in New Physicians | 0 comments

Please welcome the physicians who joined our staff in March.

Joshua Kayman, M.D.
2001 Dwight Way
Berkeley, CA. 94704

Joshua Kravetz, D.O.
Emergency Medicine
2000 Crow Canyon Place. Suite 260
San Ramon, CA. 94583

From Medical Staff Services