Emergency Operations Plan

Posted on Jul 2, 2018 in Uncategorized | 0 comments

Emergency Operations Plan
Know how to respond and prepare for Disasters

In the event of a disaster, Sutter East Bay Hospitals will utilize Emergency Operation Plans.  An announcement will be made overhead calling a triage code.  Medical Staff within our facilities will be identified and asked to report to the the Labor Pool. Physicians who are out of the hospital and responding to our call for assistance should report to the same campus specific locations. Please remember to bring your identification badge.

Sutter East Bay Hospitals have implemented facility specific, comprehensive, all hazards Emergency Operations Plans in order to assure the most appropriate hospital response to the medical needs of the community in the event of an emergency/disaster situation or a mass casualty incident.  This all-hazards plan complies with elements of the National Incident Management System (NIMS) and incorporates the Hospital Incident Command System (HICS) and addresses the six critical areas mandated by Joint Commission standards.

A complete Hazard Vulnerability Analysis (HVA) is conducted annually to identify potential emergencies (natural and man-made) that could increase the need for the organization’s services, or its ability to provide those services. A multidisciplinary committee, including physicians, annually updates the HVA.

Medical staff can communicate potential emergency needs to the Emergency Preparedness Committee and/or the Emergency Preparedness Coordinator.

During a disaster, demand for care may exceed the ability to deliver healthcare. Disaster privileges may be granted to Volunteer Licensed Independent Practitioners after presenting documentation and completing a verification process by the Medical Staff Office.  A temporary badge will be presented and they will be paired with credentialed facility Medical Staff members.

There is a cache of emergency supplies on site.  In the event that the medical center requires additional resources, such as food, water, supplies, etc. there are Memorandums of Understanding (MOUs) in place to assure that the medical center receives priority in obtaining these resources.

In a healthcare surge focus may shift from patient-based care to population-based outcomes as determined by the California Department of Public Health. Appropriate standards of care may also vary based on the availability of resources, patient needs and environmental factors.  Medical Care is coordinated and guidance is provided by the Medical Staff Specialist in the Hospital Command Center and implemented by the Medical Care Branch Director (HICS identified positions).

When you hear a triage code # overhead or receive a call from the hospital letting you know that our Emergency Operations plan has been activated:

  • Go to the Medical Staff Office for Eden and Delta Providers; or the Labor Pool for Alta Bates Summit.
  • Bring your ID badge

We have an up-to-date Emergency Operations Plan in place and practice using it at least twice per year.

A committee consisting of physicians and persons from a variety of disciplines annually updates the Hazard Vulnerability Analysis.

Medical Staff Office personnel verify credentials and coordinate approval of disaster privileges for volunteer licensed independent practitioners who present proper documentation.  Disaster privileges will be exercised under the supervision of the Chair of the applicable department.  The volunteer practitioners will work with credentialed Medical Staff members.

When shifting to population-based care, medical care is:

  • Coordinated by the Medical Staff Specialists in the Hospital Command Center
  • Implemented by the Medical Care Branch Director

CMS Verbal & Telephone Order Compliance is on the Radar for CMS! 

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

CMS Verbal & Telephone Order Compliance is on the Radar for CMS!  VO/TO orders are required to be signed within 48 hours:

  • Current compliance is down at 81% through May. ABSMC benchmark for compliance is 90% or greater
  • Specialties with over 100 orders at 90% or greater compliance for the May

–              Emergency Medicine
–              Radiology Diagnostic and Interventional

  • Specialties with over 100 orders at 80% or greater compliance for May

–              Anesthesiology
–              Cardiothoracic Surgery
–              Critical Care Medicine
–              Hospitalist Medicine
–              Internal Medicine
–              Orthopedic Surgery
–              Physical Medicine and Rehab
–              Psychiatry

  • Specialties with over 100 orders: Opportunity for improvement

–              Cardiology
–              General Surgery
–              Hematology/ Oncology

Help make a difference! We are asking for your assistance in signing your VO/TO within 48 hours:

  • Please remember that you can sign orders for your colleagues.
  • Hardwire signing off on orders every day and before you go off shift.
  • Be survey ready now!

Suspension Criteria Change approved at March MEC:

  • As a reminder, HIM will begin suspending for all “Review” deficiencies for missing information starting the week of July 16. This includes:

–              Missing required content such as EBL or specimens removed
–              Missing or incorrect discharge dates
–              Missing final diagnosis or discharge summary content

History and Physical Reminders:

  • H&P is required to be recorded in the patient chart prior to surgery. This includes a scanned H&P
  • If H&P is within 30 days of the current surgery, provider is required to document the H&P interval update after admission but prior to surgery
  • If you are using your office H&P, please ensure you copy and paste your office H&P to the correct surgical encounter

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


Posted on Jul 2, 2018 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.

New Standard Codes

Posted on Jul 2, 2018 in Uncategorized | 0 comments

Wellness Intranet Page

Posted on Jul 2, 2018 in Announcements | 0 comments

Sutter Community Connect – Epic

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

NO Beverages Left Behind!

Posted on Jul 2, 2018 in Uncategorized | 0 comments


Please do not leave beverages at the Nursing Stations.


Welcome New Physicians

Posted on Jul 2, 2018 in New Physicians | 0 comments

Melissa S. Burroughs Pena, MD
Cardiovascular Disease
Cardiovascular Consultants Medical Group
365 Hawthorne Ave., Ste. 101
Oakland, CA  94609-3115

(510) 452-1345

Skylar H. Johnson, MD
Emergency Medicine
Berkeley Emergency Medical Group
2450 Ashby Ave.
Berkeley, CA  94705

(510) 204-4723

Sara J. Westergaard, MD
Hospitalist, Medical
East Bay Physicians Medical Group
2450 Ashby Ave., Rm 5505
Berkeley, CA  94705

(510) 204-1893

From the Medical Staff Office

Message from the President – June 2018

Posted on Jun 5, 2018 in President's Message | 0 comments

Medical Staff Leaders recently completed Sutter Safe Care Leadership training. A special thank you is extended to everyone who donated eight hours out of their busy schedule to participate. We learned during the training that Sutter Safe Care is about creating a safe environment for not only our patients, but also for everyone in hospital. Zero harm is our goal.

Sutter Safe Care is about having a preoccupation with failure and safety, and linking this to our decisions to help create a safe environment for all. It’s about addressing potential safety issues before they become problems and cause harm. It’s about speaking up about issues we encounter on a daily basis, and thanking individuals for bringing up their concerns. It’s about actively finding problems and fixing the proximate causes. Also, it’s about changing our culture by creating an environment of trust and cooperation.

A more technical aspect of Sutter Safe Care is changing some of the details of our reporting system to better categorize events that could lead to harm or have caused harm e.g. Intensive Analysis (IAs) and Root Cause Analysis (RCAs). This will help us as an organization better understand patterns of safety events and create solutions within our system to avoid these events from occurring in the future.

Furthermore, there is an emphasis on “Just Culture”, or in other words, having a fair and accountable culture, which is understanding that most events are unintentional. When a safety event occurs, rather than blaming the individual, we take a deep dive into our system and determine how we can prevent future incidents through improving our systems. Also, as physicians and care givers, we hold ourselves accountable to our patients and each other.

The dates, times, and location for the two hour Sutter Safe Care sessions will be emailed soon.

Remember, if you see a problem or potential problem, please report it to your unit manager or to your Medical Staff leader, either your Department Chair or Medical Director. Below is an outline of the Medical Staff leadership reporting structure.

Required two hour training sessions for physicians and staff will occur June through September. Many options will be available at varying times of the day. Specifically, there will be a few grand rounds dedicated to Sutter Safe Care training. Administration will sponsor dinner sessions at both the Summit and Alta Bates Campuses for physicians and allied health professionals. Also, you can join the hospital staff during any of their training sessions. It’s the same training. Please be sure to sign up and sign in to receive participation credit. CME credits are also available. Thank you in advance for participating in the quest toward zero harm!

A special thank you goes out to each and every physician and allied health professional caring for our patients during the unexpected downtime which began the night of May 14th. Around 10:30 p.m., activation of the fire suppression system in the Sacramento data center forced an immediate shut down of all of Sutter’s data systems. All Sutter computer services and systems were down. Our physicians, nurses and staff worked side by side quickly pulling together all available resources during this unfortunate event. While walking through every floor and visiting almost every department, I noticed a strong sense of camaraderie and team work. Adversity brought out the best in everyone despite the challenges we faced. Radiologic studies were read at the bedside. Lab results were both hand delivered and faxed. Physicians heard through the grapevine potential consultations and without being called, came to the patient’s bedside.

Two radiologists deserve recognition: Dr. Phillip Wong and Dr. Chris Lee. The night hawk service was unable to function without computer services, therefore, no teleradiology. Both radiologists came in to care for our patients the night of the outage despite not being on call so studies could be read in real time. Thank you Drs. Lee and Wong.

Sutter is doing a deep dive into the circumstances surrounding the unexpected downtime. They will report their findings to each affiliate and we will report the findings via the medical staff newsletter. Also, we are doing our own debriefing as there is a lot we can learn as this situation simulated a true disaster. Please escalate downtime concerns, or ideas to streamline downtime procedures to your unit manager, Medical Director, or Medical Staff Chair. We can learn from your experience.

Chain of Command

Posted on Jun 5, 2018 in Uncategorized | 0 comments