President’s Message

Posted on Apr 2, 2019 in President's Message | 0 comments

Happy Spring everyone!

The definition of spring includes to originate or arise from, leap, burst forth, rise up. We, as physicians, need to “spring” into leadership positions across our health care system. As we all are well aware, we are facing a health care crisis. Physicians deeply understand issues within the health care system, and we are poised to enable change, as we understand the symptoms that need treatment. Our Medical Staff organization is the way we can use our voice to begin to make necessary changes. If we relegate ourselves to only showing up to work, seeing patients, and going home, we are missing a large part of how we can effect change and help our patients on a broader level.

In the past, physicians lead hospitals. As more demands were placed on physicians, physicians began to step out of leadership roles and non-clinicians stepped in to fill the gap. This trend continues. Residency programs do not teach newly-minted physicians how to lead or engage with the hospital system, further exacerbating this problem. This has led many physicians to feel disengaged and powerless to elicit change. I am here to tell you that not only can we effect change, but we can lead change.

As mentioned in the previous Medical Staff Newsletter, our Medical Staff plays an important role providing physicians both a voice and a seat at the table in the hospital. We lead many hospital committees and serve as committee members. These committees include Quality (Medical Staff Performance Improvement), Risk and Patient Safety, Pharmacy and Therapeutics, Medical Records, Ethics, Physician Well Being including the Well Being of Practitioners and the Wellness Branch, Infection Control, Operating Room Executive Committee, Continuing Medical Education, Utilization Management, Interdisciplinary Practice, Credentials, Leadership/Administration, Officer’s, and the Medical Executive Committee. We also hold Departmental meetings including Surgery, Medicine, Anesthesia, Emergency Medicine, Nephrology, Oncology, Critical Care, CT Surgery, Orthopedics, Gynecology, Psychiatry and Peer Review. Each of these meetings serves an important role in the functioning of this hospital. These meetings allow us an opportunity not only to learn what is happening at the medical center, but also, importantly, to effect change.

Furthermore, at the end of every year at the beginning of November, we host the Closed Active Medical Staff Meeting where we summarize what has been happening in the hospital and in each department over the past year. At the next meeting, we will nominate the Medical Executive Committee Officers who will serve for the next two years. Please look out for the invite this fall. Dinner and wine will be served. We hope to see you there!

We need our physicians to be involved. Many committees meet once a month, every other month or quarterly. That’s not much time to dedicate compared to the amount of time we dedicate to caring for our patients. Getting involved is how we can begin to effect change that will benefit our patients and improve patient care. Please, pull up a seat to the table. We want your voice to be heard! Join a committee. Go to your department meeting. Get involved.

You can reach out to Terri in the Medical Staff Office: 510-869-6565 or to join a committee. We would love to see you!

Take care,

Jill Kacher Cobb, MD
President, Summit Medical Staff, ABSMC

Verbal and Telephone Order Compliance

Posted on Apr 2, 2019 in Announcements | 0 comments

Verbal and Telephone Order Compliance:

Your continued support is needed.   We have dropped below our 90% benchmark in both Jan and Feb 2019. A renewed focus is needed to help ensure all VO/TO orders are signed within 48 hours.   Departmental or Individual compliance can be obtained through your Department Chair or HIM Manager-Alisa Stinn.

Sutter Community Connect

Posted on Apr 2, 2019 in Announcements | 0 comments

Reducing Low-Risk, First-Birth C-Sections

Posted on Apr 2, 2019 in Announcements | 0 comments

One of the advantages of practicing medicine within a large integrated healthcare delivery network like Sutter is that we benefit from studying the experience and practice patterns of our fellow clinicians. A great example of this is the work happening around supporting vaginal delivery by reducing the rate of cesarean sections for low-risk, first-time births (nulliparous term singleton vertex, commonly referred to as NTSV).

Sutter’s integrated network enables sharing of best practices and real-time data for continual process and quality improvement, which allows Sutter to outperform state and national averages in many quality measures and improve outcomes for the communities it serves. Sutter hospitals have been leaders in the state in lowering C-section rates—notably NTSV C-section rates.

A recent news story on C-section rates highlights the excellent work led by The Sutter Health Women’s Affiliated Group (SHWAG) and demonstrates what is possible when 18 Sutter-affiliated OB groups work together toward a common goal.

The Sutter Health network is a member of the California Maternity Quality Care Collaborative (CMQCC), a multi-stakeholder organization committed to ending preventable morbidity, mortality and racial health disparities in California. Partnering with CMQCC and the California Health Care Foundation, Sutter Health is leading a labor culture campaign to proactively educate first-time mothers about C-sections and encourage them to engage with their care teams to support vaginal birth and avoid C-sections for low-risk pregnancies.

Sutter Health’s NTSV C-section rate is among the lowest in California, with nine hospitals receiving recognition in 2017. Sutter’s average rate (21.2 percent) is lower than the state’s Healthy People 2020 target (23.9 percent) and the 2016 CMQCC P75 target (22.2 percent).
Studies show that a strong predictor of a woman’s chance of having a C-section is the hospital where she delivers, including the practice pattern of the physician/midwife and clinical team. As of January 2019, there is still considerable variation in affiliate performance across Sutter Health, ranging from 12.3 percent to 28.1 percent. In an effort to reduce this variation, we partnered with CMQCC to analyze our 2017 labor culture survey findings and identify qualities of hospitals with lower C-section rates versus those with higher rates. Our OB leaders are developing tools to provide insight into the foundational beliefs of physicians and staff relative to C-sections and how those beliefs impact vaginal birth rates.

There are several key drivers that have been instrumental to achieve real progress in decreasing C-section rates among Sutter Health affiliates.
• The first and most important driver is effective communication and teamwork—a joint commitment by the clinical team (nurses, midwife and physician) to create a great supportive environment for our patients.
• The second driver is alignment on best practices for labor support, including collaborative labor management and education. We adopted a labor dystocia checklist in labor and delivery that establishes parameters clinicians need to complete before deciding on a C-section. The teams work collaboratively using the checklist to ensure that all best practices for supporting a vaginal birth have been implemented. We have implemented the labor dystocia checklist at 13 sites, with a planned roll out to the remaining five OB sites in 2019. Additionally, we have developed labor support education for nurses, midwives and physicians. The next step, which we are now working on, is to include the patient as part of the team as we work through the checklist.
• The third driver is maternal agency—we have created a birth preference sheet to educate new mothers about choices they make that may increase their likelihood of a vaginal delivery and give them the opportunity to talk with their physician or midwife about these choices before birth.
• Finally, a large component of lowering NTSV C-Section rates is the open sharing of physician-level rates among our peers. This transparency creates the opportunity for dialogue and shared learning among clinicians. Each group is encouraged to discuss these rates internally and come up with a plan to address any issues uncovered by the data.

Our goal is that every patient receives the same high quality OB care regardless of which Sutter Health affiliated hospital she delivers at.
We will introduce a suite of resources over the coming months to support this initiative, including a labor and delivery web page, a series of videos and resources for patients and clinicians.

For more information, please reach out to the women’s medical director or OB/GYN chair at your affiliate.

Third Annual Mindfulness Retreat for Physicians – All Clinicians Welcome

Posted on Apr 2, 2019 in Announcements | 0 comments

Third Annual Mindfulness Retreat for Physicians
All Clinicians Welcome!
Saturday June 8, 2019
Full Day 9:30am – 4:30pm
Green Gulch Farm, Muir Beach, CA
Meditation and Stress Reduction Practices
Build Resilience and Learn Tools to use during Busy Work Day
Increase Physician/Clinician Well-Being

       Mindfulness is defined as “the non-Judgmental awareness of the present moment.” It is the art of paying attention in a compassionate way, a strategy that brings both relaxation and energy leading to a greater sense of control, agency, meaning, and Well-Being.

        The retreat will provide teaching of the forms of meditation shown by meta-analytic research efforts to have the most benefits. Attendees will be able to teach Mindfulness techniques to others such as partners, colleagues and patients. Attendees will directly experience the benefits of Meditation during the retreat and be able to employ them daily at work.

     The purpose of the retreat is to introduce mindfulness to physicians who are facing burnout, who want to learn this approach for their own health, and for greater balance in their relationships with colleagues, patients, and families. The retreat will be held at Green Gulch Farm, a gorgeous retreat center in Marin County adjacent to Muir Beach.

Retreat Highlights

  • Proven techniques based in Positive Psychology, Cognitive Behavioral Therapy, and Meditation
  • Practice of sitting and walking meditation, mindful yoga, and body scan
  • Group discussion on ways to incorporate mindfulness in the Clinic or Hospital setting
  • Vegan lunch, and built-in hour for hiking at Muir Beach (or a nap under a tree if you prefer!)


Scott Roberts, MA, PhD Candidate, Psychology Professor, researcher in the neuroscience of meditation and natural environments, NLP, RYT; Lenny Husen, MD Internal Medicine, Chair of the Alta Bates Summit Wellness Committee and Peer Support programs; John Mouratoff, MD, East Bay Nephrology, coordinator of Physicians Mindfulness Meditation Group.

Stillwater Hall, Green Gulch Farm and Zen Center
1601 Shoreline Highway, Muir Beach, CA 94965

Retreat fee is $125 including coffee/tea, snacks throughout day, and vegan lunch

How to Register

Please email Lenny at your name and where you work
Payment required to reserve a spot (there is space for about 25 people)
Snail mail: Send Check payable to Lenny Husen, 1080 Brown Avenue, Lafayette, CA 94549
Pay via PayPal: to Lenny Husen Physician Wellness

New Providers Memo

Posted on Apr 2, 2019 in New Physicians | 0 comments

Rudra D. Barua, MD
Radiology, Diagnostic
Bay Imaging Consultants Medical Group, Inc.
2125 Oak Grove Rd., Ste. 200
Walnut Creek, CA  94598
(855) 424-2723
Francisco J. Fletes, MD
Virtual Medical Staff, LLC
2655 Northwinds Pkwy
Alpharetta, GA  30009-2280
(877) 732-7089
Laura A. Hotchkiss, MD
Radiology, Diagnostic
Direct Radiology, LLC
1839 N. Government Way, Ste B
Coeur d Alene, ID  83814
(855) 687-7237
Joseph N. Morgan, MD
Radiology, Diagnostic
Bay Imaging Consultants
2125 Oak Grove Rd., Ste 200
Walnut Creek, CA  94598-2520
(855) 424-2723
Elliot L. Naidus, MD
Pulmonary/Critical Care Medicine
East Bay Regional Critical Care & Pulmonary
411 30th St., Ste. 314
Oakland, CA  94609
(510) 841-0689
Muhammad Rehan A. Puri, MD
Virtual Medical Staff, LLC
2655 Northwinds Pkwy.
Alpharetta, GA  30009-2280
(877) 732-7089
Shree J. Shah, MD
Radiology, Diagnostic
Direct Radiology, LLC
1839 N. Government Way, Ste. B
Coeur d Alene, ID  83814
(855) 687-7237

President’s Message

Posted on Mar 4, 2019 in President's Message | 0 comments

Happy Doctor’s Day a bit early!
On Friday, March 29, in the Bay View Room on the 11th floor,
we will celebrate Doctor’s Day. A breakfast and lunch buffet will be served on behalf of the Hospital
Administration in appreciation and support of the Medical Staff.
Also, if you pre-ordered a zip-up sweat shirt, they will be available. Thank you to Administration for the gift!

It’s that time of the year: JCAHO. They have been making rounds throughout the Sutter system over the last few months and will be here soon.
Below are a few tips:

-Wear your hospital ID badge.
-Wash your hands or use foam upon entering and exiting a patient room.
-Sign your verbal/telephone orders ASAP.
-Carry with you the Blue Book, which can be found at the nursing stations or drop by the Medical Staff Office to secure yourself a copy.
-Or, download a digital copy to your phone with this link:


-You can use the book or web link at any time to look up an answer.
-Most importantly, if you don’t know the answer, tell them where you can find it (ask the manager, Medical Director, or Chair of your Department).
-Follow the Universal Protocol for surgical and non-surgical invasive procedures by performing a “time-out” to correctly identify the patient, procedure, site, and availability of appropriate equipment.

On another note, many of our Medical Staff Leaders attended a Sutter Physician Leadership Symposium at the end of January. Medical Executive Committee members from across the Sutter system were invited to attend and learn more about issues related to Medical Staff Leadership including credentialing and privileging, peer review, and regulatory compliance. Not only did we learn a lot about how to better serve you, but we also reconnected with the purpose of the Medical Staff Organization.

First, a hearty thank you to the many Medical Staff Leaders who are currently serving and have served before us for your leadership and time spent doing this important job.

For those who are closer to residency training and at the beginning of your career, you may be learning about the organized Medical Staff and wondering what it’s all about. A hospital’s Medical Staff is an independently functioning, self-governed organization (separate from hospital administration), of all licensed independent physicians and other practitioners who are permitted by law to provide patient care within that hospital or facility. We are accountable to the governing body, which is the Sutter Bay Board, for quality of care. We are composed of MDs and DOs, along with other practitioners including, but not limited to, PAs, NPs, Dentists, and Podiatrists.

The Medical Staff has a set of Bylaws, Rules and Regulations, and policies we abide by. Our Bylaws provide a framework for self governance in order to permit the Medical Staff to discharge its responsibilities in matters involving the quality of medical care and to govern the orderly resolution of those purposes. The Rules and Regulations supplement the Bylaws and cover Medical Staff and hospital procedures in more detail than the Bylaws. Policies supplement the Rules and Regulations.

The Medical Staff has an important role providing physician leadership throughout many aspects of the hospital. We partner with administration, directors, managers, and the staff of many departments throughout the hospital to provide feedback and elicit change. Physician leadership is important now more than ever in our rapidly changing healthcare environment. The next newsletter will give more detail and describe how you can get involved.


Be well,

Jill Kacher Cobb, MD
President, Summit Medical Staff, ABSMC




Doctors’ Day

Posted on Mar 4, 2019 in Announcements | 0 comments



FRIDAY, MARCH 29, 2019



BREAKFAST BUFFET:  7:00 A.M. – 9:00 A.M.

LUNCHEON BUFFET:  11:00 A.M. – 1:30 P.M.


EPIC & EPIC Patient Safety Notice

Posted on Mar 4, 2019 in Uncategorized | 0 comments

Quick Reference Guide: Electronic Access to Patient Medical Records

Posted on Mar 4, 2019 in Announcements | 0 comments


Access, Use and Disclosure of Patient Health Information (PHI) Pursuant to Authorization:

 Must be limited to the minimum necessary to facilitate legitimate Treatment, Payment, or Healthcare Operations (TPO), or as required by law. Any other access, information required, use, or disclosure purpose(s) of PHI requires prior written authorization from the patient.

Access to Patient Medical Records

You may access a Patient’s electronic health record:

  • When you are the treating provider for the Patient
  • When conducting Institutional Review Board (IRB) approved research
  • For approved quality review purposes.

Documentation is essential to understanding the purpose for accessing a record. Ensure you document thoroughly, especially when the Patient is a family member.

 Access to Adult Family Member(s)/Friend(s) Medical Record(s)

Electronic access to an adult family member’s and/or a friend’s medical record is ONLY permissible if:

  • You are a health care provider and the access is for purposes of treating the family member or friend. Applicable documentation policies must be followed.
  • There is a prior signed authorization present in the EHR.

Access to Your Personal Medical Record

  • Recommend using ‘My Health Online’ to access your personal records. It is not recommended that you access your personal health records via Epic.