Committee Briefings

Update from The Well-Being Committee

Posted on Jul 7, 2017 in Committee Briefings | 0 comments

Here at Summit, we now have a bi-monthly Wellness Committee. We are interested in promoting the Wellness of the medical staff.  Here are a few of the things we are working on:

– advocating for better exercise space here at the medical center

– identify sources of frustration that leads to unhappy docs

– organizing talks on how to find meaning in our work

– providing resources for those of us who are starting to feel burned out

If you are interested in joining us, let me know. We have room for a few more people on the committee.

The weekly Mindfulness and Mediation Group run by John Mouratoff, MD and Scott Lee, MD is still meeting Wednesday at 5 pm now in the conference room by the admin offices on the 5th floor. We talk about the stresses and pleasures of our lives and then do a 20 minute mediation.  You don’t have to be experienced in mediation to join.  Scott and John’s enthusiasm is contagious and will help you!  Contact John for more info:

We all have our moments when we feel bad at work: stressed about time pressures at work, concerned we are not at home with family as much as we should be, upset about challenging case that went poorly, or frustrated about that patient who is driving us nuts! Wouldn’t it be nice if there was someone in your department who you could count on to talk informally to about these kind of issues?  As I have mentioned before, we are working with the System-Wide Sutter to bring a peer support program to our med center.   We are bringing in a program used now in 30 institutions and started at Brigham and Women’s by Dr Jo Shapiro.  We are looking for people in each department who are interested in being trained to do this peer counseling; we hope to start in the fall.  If you are interested in being involved, let me know.

Leif Hass, MD

Update from The Well-Being Committee

Posted on May 2, 2017 in Committee Briefings | 0 comments

There might be a few spots still open for the event at Green Gulch in Marin sponsored by Stresscare on 5/6. visit: This retreat introduces mindfulness to physicians who are facing burnout.

The weekly Mindfulness and Mediation Group run by John Mouratoff, MD and Scott Lee, MD is still meeting Wednesday at 5 pm typically in the Oak room on the first floor.

We are looking for people who are interested in being involved in our Peer Support Program that we hope to start in the fall. Sutter is supporting our efforts to have physicians here trained to offer support to our colleagues feeling stressed by work or feeling bad about challenging cases or case that went poorly. If you are interested in being involved, let me know.

Leif Hass, MD

Caring for an Incapacitated, Unrepresented Patient at Summit?

Posted on Aug 6, 2014 in Committee Briefings | 0 comments

The Summit Campus of ABSMC has a formal mechanism for making ethically responsible medical decisions for patients who cannot make medical decisions for themselves and who do not have a DPOA.  A Surrogate Decision-Making Team (SDT) can be requested though an ethics consult.  Unlike an ethics consult (which is purely advisory), the SDT can make decisions on major invasive treatments and on forgoing life-sustaining treatments.  The SDT is made up of 5 persons not directly involved in the patient’s care (a physician, a nurse, an MD and a non-MD Ethics Committee member and a community member or chaplain).  The team can be readily convened and is available throughout the hospital stay.  Read More

Medical Staff Performance Improvement Committee

Posted on Aug 1, 2012 in Committee Briefings | Comments Off on Medical Staff Performance Improvement Committee

The year is half over and our last MSPI meeting was in May. The departments we focused on were:

Cardiothoracic Surgery–Dr. Russell Stanten

  • Risk adjusted O/E operative mortality rates indicated all cases zero with the exception of 0.51 for isolated CABG
  • Perioperative complication rates consistently lower than national benchmark
  • SCIP measures at 100 percent
  • Prolonged vent times for isolated CABG attributed to lapse in nursing management; conducted reeducation in CPU
  • Blood wastage PI project has demonstrated significant positive impact.
  • Post-procedure LOS for isolated CABG–most patients discharge 5 days postop; benchmark < 6
  • 30-day readmission rate for all procedures averages 10 percent; benchmark range is 1-14 percent depending on procedure
  • Case volume for major thoracic surgery procedures and quality indicators for the lung cancer lobotomy dashboard from 2009-2011 were presented.

OB/Gynecology–Dr. Lee Hambrick (Data through 2011 was presented)

  • Continued decrease in OB/GYN patients; slight uptick from 2010 in number of patients transferred out of the ED, at 81
  •  2 vaginal deliveries in 2011 in the ED; volumes for GYN surgery continue to decrease and were at 392 in 2011.
  • Surgical complication rate essentially unchanged at 2.3
  • Two-fold increase in returns to surgery from 0.42 to 0.8
    • 2  cases were related to bleeding and one bladder perforation
  • No mortality
  • SCIP measures all at 100 percent
  • Peer review looked at
    • Urology On-call/Availability issue
    • Availability of hysterectomy consent forms
    • Latest prophylactic antibiotic tables for the department
    • Former chair met with EDMDs

Wellbeing of Physicians Committee (WBOP)

Posted on Jun 1, 2012 in Committee Briefings | Comments Off on Wellbeing of Physicians Committee (WBOP)

Quality medical care is a team effort and all members of the team affect the patient’s outcome. Physician members who have problems with drugs, alcohol or personality changes that affect their ability to participate as team members can get help from the Wellbeing of Physicians Committee (WBOP). The committee meets quarterly and is here to help find solutions to these problems. It is better that a physician voluntarily seek help rather than be assigned to seek help. Maintaining the standard of care for our patients is the goal, but helping the physician who may be having problems in a non-punitive fashion is the goal too.

Medical Staff Performance Improvement (MSPI)

Posted on May 2, 2012 in Committee Briefings | Comments Off on Medical Staff Performance Improvement (MSPI)

As the 2012 Vice President of the Medical Staff, I am responsible for chairing the Medical Staff Performance Improvement Committee. There is always a packed agenda.

This month’s highlights of the Medical Staff Reports presented include:

Dr. Shaieb–Transfusion
• Informed Consents remain around 90 percent.
• PPOs for Transfusion Usage only 31 percent; the majority of physicians continue to handwrite their orders for blood.
Dr. Shaieb is participating in the Regional EHR to assure that our PPOs are reflected, with education to support improvement of the use and appropriate orders.

Dr. Schlies–MPI
• Quality metrics for that program including BASIS 32 at threshold
• Referrals for patients dc’d on psychotropic medications >90 percent
• Presentation of the plan for program development: Addiction Free Pain Management. This is just getting off the ground, but there were numerous interested physicians, including surgeons, anesthesiologists and internal medicine physicians.
Dr. Stoneberg, from the palliative care service, will be asked to attend when they return in six months for an update.

Dr. Gordon–Imaging
• Critical value reporting has been consistently <30 minutes for physician notification, with means between 10-14 minutes 4th/qtr 2011.
• CT for Hot Stroke TAT for “CT Order Received to Report Called” averaging 27-29 minutes, well below the 45-minute benchmark.
We anticipate a CT closure for an update and will be using a CT trailer within the next few weeks.
• Complications from procedures and significant teleradiology variances remain low.