The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Sutter East Bay Hospitals
DBA: Alta Bates Summit Medical Center - Alta Bates campus
Org ID: 2073
2450 Ashby Avenue
Berkeley, CA  94705
(510)204-2606
www.altabatessummit.org


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 5/9/2013 5/8/2013   1/6/2015  
Hospital
Accredited 5/11/2013 5/10/2013   1/6/2015  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Hospital


Advanced Certification
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Primary Stroke Center
Certification 7/24/2013  7/23/2013  7/23/2013 



Certified
Programs
Certification
Decision
Effective
Date
Last Full
Review Date
Last On-Site
Review Date
Joint Replacement - Hip
Certification 5/31/2013  5/30/2013  5/30/2013 
Joint Replacement - Knee
Certification 5/31/2013  5/30/2013  5/30/2013 



Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
This measure is not applicable for this organization.
Not displayed
  Footnote Key
1. The measure or measure set was not reported.
2. The measure set does not have an overall result.
3. The number is not enough for comparison purposes.
4. The measure meets the Privacy Disclosure Threshold rule.
5. The organization scored above 90% but was below most other organizations.
6. The measure results are not statistically valid.
7. The measure results are based on a sample of patients.
8. The number of months with measure data is below the reporting requirement.
9. The measure results are temporarily suppressed pending resubmission of updated data.
10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
11. There were no eligible patients that met the denominator criteria.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Behavioral Health Care
2015 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Hospital
2015 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Oct  2013 -
Sep  2014
Heart Attack Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Heart Failure Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Hospital-Based Inpatient Psychiatric Services See Detail
This organization’s performance is below the target range/value.
This organization’s performance is below the target range/value.
Perinatal Care See Detail
Not displayed.
2
Not displayed.
2
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Stroke Care See Detail
Not displayed.
8
Not displayed.
8
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Blood Vessel Surgery
See Detail
Not displayed.
3
Not displayed.
3
  • Colon/Large Intestine Surgery
See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hip Joint Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Knee Replacement
See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
 
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
Sutter East Bay Hospitals  *
DBA:  Alta Bates Summit Medical Center - Alta Bates campus
2450 Ashby Avenue
Berkeley, CA  94705
Joint Commission Advanced Certification Programs:
  • Primary Stroke Center
Joint Commission Certified Programs:
  • Joint Replacement - Hip
  • Joint Replacement - Knee
    Services:
    • CT Scanner (Imaging/Diagnostic Services)
    • Dialysis Unit (Inpatient)
    • Ear/Nose/Throat Surgery (Surgical Services)
    • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
    • Gastroenterology (Surgical Services)
    • General Laboratory Tests
    • GI or Endoscopy Lab (Imaging/Diagnostic Services)
    • Gynecological Surgery (Surgical Services)
    • Gynecology (Inpatient)
    • Hematology/Oncology Unit (Inpatient)
    • Inpatient Unit (Inpatient)
    • Interventional Radiology (Imaging/Diagnostic Services)
    • Labor & Delivery (Inpatient)
    • Medical /Surgical Unit (Inpatient)
    • Medical ICU (Intensive Care Unit)
    • Neurosurgery (Surgical Services)
    • Normal Newborn Nursery (Inpatient)
    • Nuclear Medicine (Imaging/Diagnostic Services)
    • Ophthalmology (Surgical Services)
    • Orthopedic Surgery (Surgical Services)
    • Orthopedic/Spine Unit (Inpatient)
    • Outpatient Clinics (Outpatient)
    • Plastic Surgery (Surgical Services)
    • Post Anesthesia Care Unit (PACU) (Inpatient)
    • Surgical ICU (Intensive Care Unit)
    • Surgical Unit (Inpatient)
    • Teleradiology (Imaging/Diagnostic Services)
    • Thoracic Surgery (Surgical Services)
    • Ultrasound (Imaging/Diagnostic Services)
    • Urology (Surgical Services)
    • Vascular Surgery (Surgical Services)
    Sutter East Bay Hospitals
    DBA:  Alta Bates Summit Medical Center - Herrick campus
    2001 Dwight Way
    Berkeley, CA  94704
      Services:
      • Administration of Blood Product (Outpatient)
      • Administration of High Risk Medications (Outpatient)
      • Anesthesia (Outpatient)
      • Behavioral Health (Day Programs - Adult/Child/Youth)
        (24-hour Acute Care/Crisis Stabilization - Adult/Child/Youth)
        (Partial - Adult/Child/Youth)
      • Eating Disorders/Adult/Child/Youth)
        (Inpatient - Adult/Child/Youth)
        (Outpatient - Adult/Child/Youth)
        (Day Programs - Adult/Child/Youth)
        (Non 24 Hour Care - Adult/Child/Youth)
        (24-hour Acute Care/Crisis Stabilization - Adult/Child/Youth)
        (Partial - Adult/Child/Youth)
      • Family Support (Non 24 Hour Care)
      • General Laboratory Tests
      • Outpatient Clinics (Outpatient)
      • Peer Support (Non 24 Hour Care)
      Sutter East Bay Hospitals
      DBA:  Alta Bates Summit Medical Center - 3011 Telegraph Avenue
      3011 Telegraph Avenue
      Berkeley, CA  94705
        Services:
        • Outpatient Clinics (Outpatient)
        Sutter East Bay Hospitals
        DBA:  Alta Bates Summit Medical Center - 3030 Telegraph Avenue
        3030 Telegraph Avenue
        Berkeley, CA  94705
          Services:
          • Outpatient Clinics (Outpatient)
          Sutter East Bay Hospitals
          DBA:  Alta Bates Summit Medical Center - 5730 Telegraph Avenue
          5730 Telegraph Ave.
          Oakland, CA  94609
            Services:
            • Outpatient Clinics (Outpatient)
            Sutter East Bay Hospitals
            DBA:  Alta Bates Summit Medical Center - 5700 Telegraph Avenue
            5700 Telegraph Avenue
            Oakland, CA  94609
              Services:
              • Outpatient Clinics (Outpatient)
              Sutter East Bay Hospitals
              DBA:  Alta Bates Summit Medical Center - Lafayette Women's Health
              3595 Mount Diablo Blvd. Suite 350
              Lafayette, CA  94549
                Services:
                • Outpatient Clinics (Outpatient)

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