The Joint Commission
Quality Check
Quality Report

Summary of Quality Information
Sutter East Bay Hospitals
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   5/8/2013  
Hospital
Accredited 5/11/2013 5/10/2013   5/10/2013  


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
2013 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
2013 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:
Jan  2013 -
Dec  2013
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.
Pneumonia 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.
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 similar to the target range/value.
This organization’s performance is similar to 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
Alta Bates Summit Medical Center - 3011 Telegraph Avenue
3011 Telegraph Avenue
Berkeley, CA  94705
    Services:
    • Outpatient Clinics (Outpatient)
    Alta Bates Summit Medical Center - 3030 Telegraph Avenue
    3030 Telegraph Avenue
    Berkeley, CA  94705
      Services:
      • Outpatient Clinics (Outpatient)
      Alta Bates Summit Medical Center - 5700 Telegraph Avenue
      5700 Telegraph Avenue
      Oakland, CA  94609
        Services:
        • Outpatient Clinics (Outpatient)
        Alta Bates Summit Medical Center - 5730 Telegraph Avenue
        5730 Telegraph Ave.
        Oakland, CA  94609
          Services:
          • Outpatient Clinics (Outpatient)
          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)
            • 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)
            Alta Bates Summit Medical Center - Herrick campus
            2001 Dwight Way
            Berkeley, CA  94704
              Services:
              • 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)
              • Radiation Oncology (Imaging/Diagnostic Services)
              • Rehabilitation Unit (Inpatient, 24-hour Acute Care/Crisis Stabilization)
              • Ultrasound (Imaging/Diagnostic Services)
              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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