Sequoia Surgical Pavilion
Walnut Creek, California 94598
Patient Rights and Ethics
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard |
|---|---|---|
| Billing Ethics |
Surgery centers should publish prices, and provide patients with complete billing information and access to a representative that can quickly resolve billing issues. In addition, surgery centers should not sue patients over late or unpaid bills. |
 CONSIDERABLE ACHIEVEMENT |
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This surgery center does not publish pricing information for common procedures. This surgery center provides a detailed bill within 30 days of receiving insurance payments: Yes This surgery center provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes This surgery center sues patients: No |
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| Health Care Equity |
Surgery centers should examine their own data to identify any differences in processes or outcomes for patients of different races and ethnicities, and patients who speak different languages. Surgery centers should also put action plans in place if differences are identified. |
 LIMITED ACHIEVEMENT |
| Informed Consent |
Surgery centers should ensure that all patients are fully aware of risks and alternatives prior to procedures. |
 ACHIEVED THE STANDARD |
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All staff involved in the informed consent process achieve the appropriate training: Yes Doctors explain expected difficulties and recovery time and allow patients to ask questions: Yes Doctors involved in the procedure are listed on the consent form, and patients are notified if the doctor will be absent and if trainees will be involved: Yes Consent forms are written at a 6th grade reading level: Yes Staff ask patients about their preferred language for decision-making and make a trained medical interpreter available if appropriate: Yes Doctors use the "teach back method" to ensure patients understand what will be performed and what are the risks: Yes |
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| Responding to Never Events |
Surgery centers should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. |
ACHIEVED THE STANDARD |
More Information
| Protocol to collect and respond to patient-reported concerns about care |
This surgery center does have a protocol to collect and respond to patient-reported concerns about care.
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Preventing Patient Harm
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Percentage of Registered Nurses (RNs) who have a Bachelor’s Degree in Nursing |
Surgery centers should have a high proportion of highly trained and skilled registered nurses (RNs) who have an advanced nursing degree. |
CONSIDERABLE ACHIEVEMENT |
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| Effective Leadership to Prevent Errors |
Surgery centers should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety. |
CONSIDERABLE ACHIEVEMENT |
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This surgery center scored 109.09 out of 120.00 possible points. |
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| Staff Work Together to Prevent Errors |
Surgery centers should have assessed their culture of safety and held leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety. |
CONSIDERABLE ACHIEVEMENT |
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This surgery center scored 106.67 out of 120.00 possible points. |
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| Staff Identify and Mitigate Risks Associated with Errors |
Surgery centers should use retrospective and prospective data sources, including patient reports, to identify and mitigate errors that harm patients including medication errors and infections. |
CONSIDERABLE ACHIEVEMENT |
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This surgery center scored 83.33 out of 100.00 possible points. |
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| Handwashing |
Surgery centers should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Surgery centers foster a culture of good hand hygiene, offer training and education, and have provided equipment, such as paper towels, soap dispensers, and hand sanitizer. |
ACHIEVED THE STANDARD |
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Healthcare-Associated Infections
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard |
|---|---|---|
| Tracking and Reporting Accidents and Infections |
Surgery centers should track and report all applicable accidents such as burns, falls, errors, surgery center admissions and surgical site infections, to a national database. |
ACHIEVED THE STANDARD |
Medication Safety
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Medication Documentation for Elective Outpatient Surgery Patients |
Surgery centers should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record. |
ACHIEVED THE STANDARD |
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Complex Adult Surgery
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard |
|---|---|---|
| Bariatric Surgery for Weight Loss |
Facilities should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. |
DOES NOT APPLY |
| Total Knee Replacement Surgery |
Surgery centers should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. |
ACHIEVED THE STANDARD |
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This surgery center performed 293 total knee replacement surgeries compared to Leapfrog’s standard of 50 procedures annually. As part of their process for privileging surgeons, this surgery center does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total knee replacement surgeries. |
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| Total Hip Replacement Surgery |
Surgery centers should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. |
ACHIEVED THE STANDARD |
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This surgery center performed 219 total hip replacement surgeries compared to Leapfrog’s standard of 50 procedures annually. As part of their process for privileging surgeons, this surgery center does ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 25 procedures annually for total hip replacement surgeries. |
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Elective Outpatient Surgery - Adult
Neurosurgery
| Procedure | Number of Procedures Performed Annually |
|---|---|
| Spinal Fusion Procedures | 9 |
Orthopedic (Bones and Joints)
| Procedure | Number of Procedures Performed Annually |
|---|---|
| Finger, Hand, Wrist, Forearm, and Elbow Procedures | 1,167 |
| General Orthopedic Procedures | 527 |
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Hip Procedures
(Does not include total hip replacements – see Total Joint Replacement)
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251 |
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Knee Procedures
(Does not include total hip replacements – see Total Joint Replacement)
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1,485 |
| Shoulder Procedures | 1,513 |
| Spine Procedures | 91 |
| Toe, Foot, Ankle, and Leg Procedures | 758 |
Elective Outpatient Surgery - Pediatric
Orthopedic (Bones and Joints)
| Procedure | Number of Procedures Performed Annually |
|---|---|
| Finger, Hand, Wrist, Forearm, and Elbow Procedures | 44 |
| General Orthopedic Procedures | 10 |
| Knee Procedures | 65 |
| Shoulder Procedures | 7 |
| Toe, Foot, Ankle, and Leg Procedures | 18 |
Care for Elective Outpatient Surgery Patients
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Elective Outpatient Surgery Recovery Staffing - Adult |
Surgery centers should ensure that a specially certified clinician is present and immediately available while an adult patient is present until discharge. |
ACHIEVED THE STANDARD |
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| Elective Outpatient Surgery Recovery Staffing - Pediatric |
Surgery centers should ensure that a specially certified clinician is present and immediately available while pediatric patient is present until discharge. |
ACHIEVED THE STANDARD |
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| Safe Surgery Checklist - Elective Outpatient Surgery |
Surgery centers should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed. |
ACHIEVED THE STANDARD |
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| Experience of Patients Undergoing Elective Outpatient Surgery |
Surgery centers should perform better than most on four (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients' willingness to recommend the facility. |
CONSIDERABLE ACHIEVEMENT |
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Performance on the following four domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey make up a surgery center’s score on Leapfrog’s “Experience of Patients Undergoing Elective Outpatient Surgery” measure. “Top Box Score” represents the percentage of respondents who gave the most favorable response.
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| Unplanned Hospital Visits after Colonoscopy |
Unplanned hospital visits can occur when patients experience complications after a colonoscopy procedure. Facilities should have a rate of unplanned hospital visits that is lower than most hospitals and surgery centers. |
DOES NOT APPLY | ||||||||||
| Unplanned Hospital Visits after Orthopedic Procedures |
Unplanned hospital visits can occur when patients experience complications after an orthopedic procedure. Facilities should have a rate of unplanned hospital visits that is lower than most surgery centers. |
UNABLE TO CALCULATE
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| Unplanned Hospital Visits after Urology Procedures |
Unplanned hospital visits can occur when patients experience complications after a urology procedure. Facilities should have a rate of unplanned hospital visits that is lower than most surgery centers. |
DOES NOT APPLY | ||||||||||
Sequoia Surgical Pavilion
2405 Shadelands Dr, Suite 200
Walnut Creek, California 94598
| Map and Directions | |||||||||||||||||
| Visit facility’s website | |||||||||||||||||
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