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Ready Set for Flu Vaccine 
All TB and Flu paperwork must now be completed online.  Click here for registration instructions.
In This Issue
New Regional Medical Staff Committees
Two new regional Medical Staff committees have been created. Dr. George Gellert and his Informatics team have established the Regional Health Informatics Committee. Physician champions in each medical specialty from each campus participate in order-set development and streamlining of the electronic medical record processes.
The Radiation Protocol Committee, led by Regional Radiation Safety Officer Homayoun Hemmat, will address State regulatory requirements regarding fluoroscopically-guided interventional procedures.

2014 President of the Medical Staff

Marc Chalaby, MD will become the next President of the Medical Staff. He has completed his service as Medical Center's Chief of Staff, and is committed to further serving our medical community.

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December 2013

As editor of this newsletter, it is my goal to provide you with pertinent and timely information. We always appreciate your feeback in order to continually improve communications to our medical staff. 
Regional Director of Medical Education
CHRISTUS Santa Rosa Health System
Jim Martin, MD
Message from the CMO 


Now that our federal government is working again, components of the Affordable Care Act (ACA) regulations are moving forward with implementation and becoming more obvious and personal to each of us.  While there are significant differences in opinions or philosophies within our Medical Staff toward specific sections of the ACA, I believe that we all understand that we must partner to meet the aims of the ACA:

  1. Improve the quality of care
  2. Improve the health to our communities
  3. Bend the cost curve downward

Addressing the cost of care is being tied to the value perceived by the purchaser to the reimbursement amount. A not so philosophical question being asked by payors is why they should pay us as hospitals or physicians for care that does not conform to quality standards or demonstrate an effort on our part to improve the health status of the insured patient or population. CMS (Medicare and Medicaid) are now aggressively recouping payments that were made to hospitals in which the hospital did not document the appropriate quality of care provided or justification for services provided. Called RAC audits, this CMS effort to assess the value is resulting in many millions of dollars being reimbursed to the government payer purely for poor documentation regardless of a good outcome.


Read on

Influenza Vaccination is Required Annually
  shot_preparation.jpgBased on recommendations from the Center for Disease Control and Prevention (CDC), the CHRISTUS Santa Rosa Health System requires seasonal influenza vaccination annually for all clinical providers who deliver patient care.  


If you received your annual influenza vaccination at another facility, please Click here to complete an attestation form to provide to the CSR credentialing office. 
Melora Berardo, MD
Melora Berardo, MD
Message from President of the Medical Staff


As another calendar year ends, I would like to summarize in this FOCUS some of the important issues presented to the Medical Board this year. 


Our Credentialing Department has undergone significant improvement with the help of the Greeley Company, and director Frances Ponsioen. Transition from Bexar County Credentialing occurred in October, and the department's goal is to complete new applications and "clean" reappointment files within 30 days of the application. In addition, the privilege forms for each specialty are undergoing revision; initial discussions will occur within the Credentials Committee. Draft privilege forms will then be distributed to each of the Medical Executive Committees for additional discussion.


As the transition from CHoSA continues, the Bylaws Committee has completed revisions to the Bylaws; this document will be shortly forthcoming for the Medical Staff to approve by majority vote. Modifications to the remaining three medical staff governing documents (Organization Manual, Rules and Regulations, Credentialing Manual) will continue over the next calendar year. 


During review of the Regional Hospital Contracts, the Medical Board has requested clarification, and direct physician input, of the evaluation process as it pertains to the physician contracted groups; this revised policy will be forthcoming for our review.


Thank you for your continued support of our CHRISTUS Santa Rosa healthcare ministry.

Improved Clinical Quality/Care Management Software
Midas is an improved clinical quality/care management software application that provides daily workflow tools and reports  for case managers, quality managers, risk managers, and infection control practitioners to help optimize clinical outcomes, improve utilization patterns, manage and improve discharge planning, reduce risk and harmful events, and optimize clinical reimbursement. Quality will use these tools to monitor over 3,000 clinical outcomes and process of care measures for our departments, specialties and teams to drive performance improvement. Midas offers the ability to drill down to provider and patient detail; physicians will be able to readily review their performance profiles to search for meaningful patterns in their data. Introduction to Midas will occur early 2014 prior to implementation. 


Physician Finder Service
We are currently updating listing information on our physician finder service. Through our professional call center "Physician Finder" program, we provide callers or web visitors with information about your practice and interests, 24 hours a day, seven days a week. The program is convenient for consumers and allows them to select a physician based on specific factors including specialty, location, and gender. If you would like your information updated, please e-mail Brian Betsworth, Marketing Program Manager, at with your name, mailing address, and your primary CHRISTUS Santa Rosa facility and we will send you a letter on how to update your information. 
Educational Activities

Educational Videos (not for CME credit)

For more information go to: 

healthcare home for life

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Edited and Produced by: 
Jann Harrison, RN, MSN, Regional Director of Medical Education
CHRISTUS Santa Rosa Health System