Message from the President-May 2018

Posted on May 2, 2018 in President's Message | 0 comments

Hello everyone! First, I would like to thank the Administration on behalf of the Summit Medical Staff for a lovely Doctor’s Day breakfast and lunch, along with the donation to New Day for Children, a non-profit organization supporting victims of sex trafficking. Also, thank you Chuck Prosper for your years of service as both COO and CEO at ABSMC. We wish you well in your future endeavors.

This month’s newsletter will focus on Summit campus highlights.

-This summer, we will launch our new Neuro Interventional Program. Initially, we will perform thrombectomies on patients who have had an acute thrombotic stroke. The program may expand later to include aneurysm coiling. Staff will go to Eden for training, as Eden has a well-established program.

-Dr. Rock Liu is leading our new Robotics Hernia Mentor/Case Observation program for robotic assisted hernia repair. Physicians will come from around the country to train and learn about our program. Details were published in the March newsletter.

-Construction for the new hybrid OR begins in April and will take approximately one year to finish. The hybrid OR will have all of the capabilities of a regular operating room plus built in advanced imaging technology.

-Our Preoperative Clinic, led by Dr. Catherine Stapleton, continues to ramp up its volume and is seeing a majority of patients who come through the operating room. A satellite clinic at Ashby is currently under consideration.

-MCMI is moving to a new location on Telegraph Avenue.

-The new in-house MRI will be operational at end of 2018.

-The construction for the new Doctor’s Lounge is scheduled to finish at the end of 2018. There will be a small exercise area, plenty of space to chart, a lounge and a dining area.

-Soon, construction will begin disassembling the West wing of the hospital. The disassembly will occur over five weekends, and construction will continue in this area of the hospital for 12-15 months.

-The Medical Staff has been engaging Sutter leadership about growth strategies for ABSMC. Suggestions or ideas? Please let myself, the Chair of your Department, or the Medical Staff Office know, as this is a collaborative effort.

-Sutter Safe Care Leadership training has begun. Dates and times for the two hour training for all physicians and staff will soon be released and will occur June through September. Administration will provide dinner for physician training on a few selected evening dates at both the Summit and Alta Bates campuses. Two hour training sessions will also be available during a few selected grand rounds on each campus. Physicians also may join in on the staff training sessions. The content is the same no matter which venue you choose. CME credits will be available.

Jill Kacher Cobb, MD
President, Summit Medical Staff

Alta Bates Summit Medical Center Doubles Shelters for Oakland’s Homeless

Posted on May 2, 2018 in Committee Briefings | 0 comments

Sutter Health’s Alta Bates Summit Medical Center has doubled its financial commitment to provide temporary housing to help the City of Oakland move homeless people from encampments into temporary shelters.

Alta Bates Summit CEO Chuck Prosper committed initial funding in December to purchase and deliver 20 “Tuff Shed” portable structures to shelter 40 people at Oakland’s first temporary “Safe Haven” shelter site for homeless individuals.

Impressed by the effort – a collaborative effort between the medical center, City of Oakland and Oakland Chamber of Commerce – a generous community donor has now offered to partner with Alta Bates Summit to help fund a second temporary shelter site, with 20 more units.

“We would certainly prefer people have permanent, safe, affordable housing,” Prosper says. “Homelessness here is now a public health issue, yet we must respond with compassion and respect in a way that helps people get back on their feet and lead healthier lives again.”

The initial Safe Haven pilot site opened in December on land donated by PG&E in West Oakland and met with early success: in less than three months 44 people from a nearby encampment moved onto the site, eight then moved from the site and into transitional or permanent housing, and 15 more had job interviews.

“Under Chuck Prosper’s leadership, Sutter Health has strongly stepped forward to support Oakland’s temporary homeless navigation centers by funding short-term housing and support services for our most vulnerable residents while the City and community seek long-term housing solutions,” says Barbara Leslie, President and CEO of the Oakland Chamber of Commerce. “The leadership shown by Chuck and Sutter, along with many members of Oakland’s business community, is a testament to their true commitment to the health and well-being of all Oaklanders.”

The second site – expected to open in late April – will be on property donated by the California Department of Transportation at 27th Street and Northgate Avenue, near one of the city’s largest homeless encampments. Both Safe Haven sites provide shelter to Oakland’s long-term homeless population with social services connecting clients to health services, public benefits and other resources.

The City of Oakland coordinates with volunteer, non-profit groups and private partners to staff and provide services at the designated navigation center locations. The locations are just one venue Oakland is trying to help slow the pace of homelessness. These venues are intended to be short term, emergency solution that helps residents establish stability and seek permanent affordable housing.

“We are making some progress, in small steps,” Prosper says, “and I commend Oakland’s leadership for trying any feasible idea that provides safe and secure shelter to people.”

Stacey Wells

Suspension Criteria Change Effective 6/18/2018

Posted on May 2, 2018 in Health Information Management | 0 comments

Suspension Criteria Change Effective 7/13/2018:

  • Summit MEC approved change 3/13/2018 in suspension criteria to include the following elements currently listed under “Review Deficiencies”:

Missing or incorrect Discharge / Admission Dates


Missing Discharge Diagnosis

Missing Dispositions

Missing pre/post OP diagnosis

  • Please ensure you are completing these deficiencies within 14 days of receiving as they will now be included in suspension processing.
  • Coding queries are NOT included.
  • Please work with Patty Fitzgibbons, Summit Physician Liaison if you need assistance modifying your templates to include all required information.

Content requirements for Immediate Post-Operative note and Operative/Procedure Notes:

  • Is EBL and Specimen Removed required in ALL l Immediate Post Op notes and Operative/Procedure Notes, regardless of type of operative procedure
  • YES, per Sutter Licensing and Accreditation, the Estimated Blood Loss and Specimen removed should be included in both the Immediate Post Op progress note template and the Operative /Procedure Report template regardless of operation or procedure type.
  • If there is no blood during procedure, document “ no blood loss” or NA
  • If there is no Specimen Removed, document “none”
  • Please reach out to Patty Fitzgibbons- Summit Physician Liaison if you need assistance adding these requirement to your documentation templates.

History and Physical Information:

  • You may be asked for H&P if the analyst cannot find one attached to the correct surgical encounter. To avoid this please ensure the following:
  • If you are completing your H&P in the office, please ensure you are documenting the H&P on the correct surgical encounter. You may also copy and paste your office H&P into the correct surgical encounter.  If you are using an office H&P or copy and paste functionality, please ensure your H&P dates are within 30 days of the patient admission.   H&P outside of this 30 day time period do not meet regulatory standards.

HIM Reminders

Posted on May 2, 2018 in Health Information Management | 0 comments

Out of Office Notice:

Please be reminded to notify HIM when you leave on vacation or going off service for extended period of time.  Before leaving, please complete and sign everything in your in-basket.  HIM will place you out of office which will help ensure your deficiencies do not continue to age and to ensure you will not be placed on suspension in error.

H&P Update:

Question: Is it appropriate to refer to the H&P in Care Everywhere in my H&P update note for surgery such as example below?

Answer: NO, this workflow is unacceptable for several reasons according to Dr. Bill Isenberg, (VP, Patient Safety, Office of Patient Experience) Sutter Attorney, and Health Information Management Leadership.

We are all in agreement that providers should not refer to Care Everywhere in lieu of adding an H&P to the encounter it is needed in. This workflow is unacceptable for several reasons including:

  • It needs to be on the record prior to the patient having surgery.
  • Not easy to find it in Care Everywhere. There were Care Everywhere records from several institutions so you had to know which one to click on. The date on the institutions was not 1/30. You had to click on the links and then hunt for the 1/30 note, which was labeled as a progress note, not an H&P.
  • Even if Nursing did find it, asking them to find it, print it and scan it is asking too much.
  • Care Everywhere documentation does not become part of our legal record for ROI.
  • Care Everywhere documentation does not pull into CAC software for coding.
  • Care Everywhere documentation does not clear an H&P deficiency automatically.

Alisa Stinn, RHIT
Health Information Manager / HIM Lead
Sutter Health
Alta Bates Summit Medical Center
Summit-Ashby-CCC Herrick
510-869-8741 | Direct
510-869-8856 | Fax
510-381-5181 | Mobile

Wellness Committee Update

Posted on May 2, 2018 in Announcements | 0 comments

Our “Mindfulness for Physicians” retreat mid-April was a big success.  For those interested, but unable to attend, you can always make it next year!

We are working on the final details for the “Peer Support Program to Promote Wellness”, but we have the dates either Saturday 9/15 here in the east bay or 9/17 Monday in Sacramento.  If you are planning on joining us for this half day event, save the date!  If you are interested in learning more about it, let me know!

Want to join our committee, we are always looking for new ideas and new perspectives. If you can’t spare the time, we will be coming to all the departmental meeting to ask about sources of frustration and ideas to create a healthy work culture so we will see you there!

Leif Hass, MD and member of the Wellness Committee
(510) 333-8681


Posted on May 2, 2018 in Committee Briefings | 0 comments

Welcome New Providers

Posted on May 2, 2018 in Announcements | 0 comments

JonPaul Seslar, DPM
3000 Colby St., Ste. 107
Berkeley, CA  94705-2090

(510) 647-3567

From the Medical Staff Office

Message from the President-April 2018

Posted on Apr 6, 2018 in President's Message | 0 comments

Welcome back to another edition of the medical staff newsletter! As many of you know, we have been encountering shortages of both medications and supplies. Medications have included items such as amiodarone, many antibiotics, KCL, local anesthetics, and compounded medications including drips and epidural solutions. If possible, please use oral medication for your patients, saving the limited supply of IV medications for those patients who need it the most. Also, please call ahead to pharmacy if you anticipate needing a compounded medication, such as a drip. Regarding supplies, we have experienced shortages of IV bags, sterile irrigation solution, connectors, extension sets, adaptors, stopcocks, and many more items.

Currently, we have limited allocations of certain drugs and supplies from many companies. The landscape changes weekly, and sometimes daily. Every now and again, we avert a crisis with an unexpected allotment. Emergency teams are pulled together immediately to address this ever-changing atmosphere of shortages as needed. Thank you to everyone who has participated on these teams. As this is a fluid situation, please look for the rainbow colored icon, located on every ABSMC computer, titled “Supply Backorders” listing both the current medication and supply shortages. We asked about sharing medications and supplies with other Sutter hospitals. Unfortunately, they too are on limited allotments from manufacturers and often do not have extra supplies or medications to share. Sutter has a committee, above the affiliate level, coordinating efforts whenever possible.

What has lead up to these issues? Well, there are many factors. I’ll touch on a few. Pfizer’s Kansas facility experienced quality problems leading to an almost full shut down of its major production facility impacting availability of opoids and local anesthetics. The Baxter manufacturing facility in Puerto Rico, damaged during hurricane Maria, lead to shortages in small volume drug bags. The FDA did take action to import supplies from other manufacturers located in other countries, which eased some of the supply issues.

As part of an effort to decrease misuse of opiod pain killers, the DEA called for a 25% reduction in the manufacturing of opoids last year, and an additional 20% reduction this year. This, along with the manufacturing issues at Pfizer’s Kansas facility, has led to opoid shortages. Many hospital systems across the country are experiencing opoid shortages, causing staff either to be judicious with usage and using alternative medications that are less potent, or, if available, giving alternative opoid medications in concentrations that RNs are unfamiliar. As a result, there have been reports from other hospitals of inadequate pain control, elective surgery cancellations, and overdoses due to lack of familiarity and mistakes in dosage administration. A letter was written on February 27, 2018 jointly by the American Hospital Association, the American Society of Clinical Oncology and the American Society of Health-System Pharmacists to the US Drug Enforcement Administration stating that the shortages “increase the risk of medical errors” and are “potentially life threatening”. The American Society of Anesthesiology is working with other national organizations to address these issues and stay ahead of drug shortage problems. They have been a leading advocate in Congress and are partnering with the FDA and their Office of Drug Shortages to monitor these issues and work toward solutions. So far, our hospital has not been significantly affected by opoid shortages.

On February 27, 2018, the California State Board of Pharmacy sent a Cease and Desist order to Pharmedium Services as an investigation demonstrated noncompliance with state regulations and federal good manufacturing practices. The California Pharmacy Board is currently working to identify alternative manufactures and alternative strategies in lieu of Phamedium sterile compounded and nonsterile drug products. This has placed an enormous burden not only on our pharmacy, but on all hospital pharmacies in California. At a recent ABSMC committee meeting pharmacy stated that we went from compounding 10% of compounded drugs to compounding 90% of compounded drugs in our pharmacy. What this means: first, the increase in compounding medication on site is a large burden for the pharmacy staff. Second, drugs compounded on site have a 12 hour shelf life, limiting the number of premade compounded medications available on demand. The company has 30 days to respond to this issue and hopefully we will see a resolution soon. In the meantime, please call ahead to pharmacy, if possible, if you need a compounded medication, such as a drip, STAT. Also, please give your pharmacy colleagues a kind word for their hard work.

Jill Kacher Cobb, MD

President of the Summit Medical Staff, ABSMC

Pharmacy Shortages

Posted on Apr 6, 2018 in Uncategorized | 0 comments

Dr. John Joseph Becchetti

Posted on Apr 6, 2018 in Announcements | 0 comments