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With Alta Bates Summit Medical Center on the brink of losing its accreditation, hospital officials are bracing for a crucial Thursday meeting in Chicago.  

Hospital spokesperson Carolyn Kemp said CEO Warren Kirk, Vice President of Medical Affairs Dr. John Gentile and Director of Quality Merilee Newton and two staff physicians will attend the meeting. 

At issue is accreditation by the Joint Committee on Accreditation of Healthcare Organizations (JCAHO), a crucial issue for hospitals and HMOs. JCAHO’s imprimatur is a prerequisite for coverage by many health insurers, said Mark Forstneger of JCAHO. 

Its approval means automatic approval for Medicare and Medicaid coverage, and without it, healthcare organizations must undergo a separate federal review before payments can be authorized, Forstneger said. 

The accreditation woes for Alta Bates were first revealed Nov. 6 when JACHO issued a preliminary denial of accreditation. Among the issues cited were the need to: 

• Obtain informed consent from behavioral health care patients. 

• Assure that patients with comparable needs receive the same standard of treatment, care and services. 

• Ensure safe storage of medications. 

• Ensure that medication orders are clearly written, accurately transcribed and reviewed for appropriateness. 

• Assure that medicines returned to the pharmacy are properly managed. 

• Assure that the hospital responds appropriately to actual or potential medication errors and adverse drug effects. 

• Develop individual treatment plans appropriate to each patient. 

• Create written time frames for conducting individual patient assessments. 

• Assess pain levels for each patient. 

• Restrain patients only on the basis of individual orders or an approved protocol initiated by an individual order. 

• Ensure that restraint and seclusion orders are time-limited. 

• Act to prevent or reduce hospital-caused patient infection rates. 

• Prepare plans for surgical and non-surgical procedures where sedation or anesthetics are used. 

• Maintain complete and accurate medical records for every patient evaluated or treated. 

“We have already had four recommendations removed through e-mails and telephone conversations,” said Kemp, “and we are convinced that when we present the documentation in person Thursday that the rest will be removed.” 

Kemp said she couldn’t say which four had been cleared. 

“We are fully accredited and expect to remain fully accredited,” she said. “For the third year in a row we have had the best outcomes for heart patients in the state, and our rehabilitation program for strokes and other brain injuries has been held up as a model.” 

JCAHO’s Forstneger said preliminary denials such as that issued to last November “are rarely rendered” and not issued lightly. 

He said there are four basic accreditation status the organization can issue, with the first being full accreditation, the second being provisional accreditation (“typically issued when there is a failure to rapidly correct deficiencies”), conditional accreditation (“typically when there are multiple deficiencies”)‚ and outright denial. 

The two intermediate statuses are typically resolved in two to four months, Forstneger said. 

The panel that meets Thursday will feature one JCAHO member, two experts with knowledge of the issues, and—if possible—the official who conducted the initial survey. 

The accreditation troubles occur at a time when Alta Bates Summit is a year into a labor dispute with members of the Service Employees International Union (SEIU). Union members, who represent most hospital employees other than registered nurses, have been working without a contract for a year. 

Some 200 union members gathered outside Summit Alta Bates Hospital in Oakland Saturday to protest the impasse in labor negotiations. 

Berkeley City Councilmember Kriss Worthington helped organize a Thursday night meeting attended by four state assemblymembers or their staffs that featured presentations by hospital officials. The other sponsors were Berkeley Grey Panthers and Vote Health. 

“We are very proud of the Thursday night meeting,” said Kemp. “Our leadership and physicians stood up and talked about the high quality of our medical care.” 

Worthington said the gathering was quite impressive. “It was a healthy discussion,” he said. 

The councilmember praised East Bay Assemblywoman Loni Hancock for managing the sometimes heated gathering. 

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