As we approach the end of 2021, I’d like to take a moment to stop and reflect on the great work we’ve done. These past two years have been tempestuous and it’s amazing to think of all we’ve been able to accomplish during this pandemic and while it would be impossible to name all our accomplishments, I do want to share a few.


Let me start off with our post-acute areas. I’m proud to say that our skilled nursing facilities (SNF) continue to demonstrate excellence and have received five out of five stars at Alameda and four out of five stars at Fairmont from the Centers for Medicare & Medicaid Services’ (CMS) Five Star Quality Rating System for Nursing Homes.

These star ratings illustrate the important differences in quality among nursing homes to help residents and families make better care decisions.

In addition, post-acute staff have worked diligently to prevent the spread of COVID-19 with vaccination rates for residents and staff well above 90%, exceeding State and national averages. And if that weren’t enough cause for praise, they’ve also passed all infection prevention and mitigation plan surveys from the California Department of Public Health (CDPH) with zero findings. Outstanding work!


BEST (Building Excellence, Sustainability & Trust) Initiatives

Our operations teams have also been quite busy launching initiatives to improve quality, increase revenue and decrease expenses. Through a partnership with Huron Consulting, we have started initiatives related to the revenue cycle, supply chain, pharmacy medications, and care optimization. BEST is focused on our overall sustainability to ensure we are on firm financial ground over time so that we can continue to deliver on our mission of caring, healing, teaching, and serving all.

Systemization of Sterile Processing

To ensure we are providing high-quality safe care to our surgical patients and to improve compliance with the Joint Commission, our operation teams are also standardizing best practices, equipment, education and leadership oversight in our Sterile Processing Department (SPD) throughout the system. I’m pleased to say regular rounding is now taking place in all our SPDs, including outpatient, to identify and address issue as they arise. To ensure patient safety, we are testing water and steam for purity on an ongoing basis, and we are piloting an instrument tracking system at Highland that will be expanded to the other sites.

Level II Ultrasound

I’m beyond proud that we are now offering Level II ultrasounds for high-risk obstetric patients who need this service. In the past, we’ve had to refer our patients to other organizations for this service, but today, they can stay within our system and under the care of their own AHS physician. This accomplishment is a great improvement to patient experience and satisfaction. Kudos to the team that worked tirelessly to bring this service to our patients!

Reduction in GI Lab Backlog

Speaking of improving patient experience, we have successfully decreased the backlog of patients needing a gastrointestinal (GI) procedure in our GI Lab. When we began working on this issue, we had a backlog of over 800. I’m proud to report that we have been able to bring that backlog down to just around 100 by changing the hours of operations and gaining more operational efficiencies. I know this is just the beginning as the work continues and I look forward to seeing even more reductions in backlogs.

ED Phlebotomy Now Offered 24/7

In our Highland Emergency Department, we’re adding 5.5 full time phlebotomists. This will allow us to improve patient safety and provide 24/7 phlebotomy services.

Having this capability will decrease blood contamination and in turn decrease:

  • the unnecessary antibiotic treatment of patients with contaminated blood cultures,
  • their length of stay
  • their potential antibiotic resistance and much more.

In addition, it will help us achieve our Surviving Sepsis metric and potentially save the system approximately $2-3 million per year.

New Service Line Director for Cardiovascular Services Role

We created a new role of Service Line Director for Cardiovascular services to work with the physicians in this service line to develop a physician recruitment plan, service line strategic plan, service line scorecard/metrics, creation of operating and capital budget, and service line financials. This role will provide strategy, growth and operational efficiency systemwide for cardiovascular services and continuous care and patient satisfaction for cardiovascular patients.

Our patients will benefit from new innovative services that we currently don’t provide, stabilize the availability and scheduling of new/developing procedures, provide better coordinated care between inpatient to outpatient to procedures and will decrease cancellation and increase access.


Our ambulatory colleagues also shine. They have been instrumental in battling the COVID-19 pandemic with their continued efforts to vaccinate patients, including those five years and older. To date ambulatory teams have administered more than 31,000 vaccines to patients, a heroic task considering all the challenges the pandemic has generated.

The pediatric team has also been working vigorously to connect children with wellness checks and critical vaccinations and it hasn’t gone unnoticed. In fact, this year they were recognized by the Department of Health Care Services (DHCS) as one of the top four performers in the State for childhood immunizations. Kudos to our pediatric teams for delivering top-quality care to our youngest members of the community.

But that’s not all, ambulatory demonstrated our mission of serving all by hosting two special clinics to connect new Afghan refugees with health care services, a primary care home and other food and housing resources. The clinics were part of a collaborative with Alameda County and the Community Health Center Network (CHCN).

In addition, our HealthCare for the Homeless mobile van began providing much needed dental services to our unhoused community members and we have implemented WellHealth to text reminders to patients for upcoming appointments and other health care needs.


I’m very pleased to report we have begun implementing Just Culture training to seek balanced accountability for both individuals and the organization responsible for designing and improving systems in the workplace. Training has been rolled out to management and in January it will roll out to all staff. We’re adopting a Just Culture because a fair and just culture improves patient safety by empowering employees to proactively monitor the workplace, voice concerns and participate in safety efforts in the work environment.

In addition, we’ve made leadership rounding standard work for our Executive Leadership team and we actively seek staff and physician input. Personally, it has been gratifying to hear the pride each of you take in your work and it is always a pleasure to meet with you and hear your ideas on improving our system. We continue to host weekly Leadership Desktop Chats to provide critical updates and provide a forum for open dialog where staff can ask questions of leadership. Schwartz Rounding has been implemented to support staff and sessions include powerful, open and honest conversations where employees can receive peer support as we continue to respond to the pandemic.

Information Systems

Our Information Systems have a lot to be proud of. They achieved Most Wired Level 7 Recognition, successfully completed Epic upgrades, and achieved six Stars in Epic use of functionality. I’m pleased to say we are among the highest-performing facilities and are ahead of the curve in adopting and integrating Epic into our workstreams.


Our financial outlook continues to improve along with our collecting practices which resulted in $25 million for FY21. With a lot of hard work from our finance team, we’ve been able to reduce our hospital billing accounts receivable days by 16 and our professional billing accounts receivable (AR) by a little over 20 days. This is important because the longer it takes us to bill someone the less likely we are to receive payment and accounts receivable are responsible for our cash flow, which we utilize to pay debts, salaries and other investments. Implementing Epic has been a great help and in fact we have four Epic trophies for top performance. In addition, our finance teams have achieved compliance with the Centers for Medicare and Medicaid Services Price Transparency regulation and our self-pay AR days were reduced by 9.8 resulting in $72 million.

Our list of accomplishments could easily go on for days and I want to close by acknowledging our new Chief Administrative Officers, Patricia (Patty) Espeseth, Mario Harding and Mark Brown and our new Chief Nursing Officer Romoanetia (Ro) Lofton. With new leadership and strategic planning underway, our future is bright. I look forward to 2022 and all the successes it holds for us. Thank you for everything you do on behalf of our patients every day.

Happy New Year!