September 2014

Below are the September Medical Staff Updates. As a reminder, all providers must complete the attestation at the bottom of this page by September 30.

DNV 2014 Survey Review

Kaleida Health recently completed its annual accreditation survey with DNV Healthcare Inc.  Thank you for making this year’s visit a success.

As you may be aware, the previous DNV report was not stellar and was not something that anyone was proud of. Earlier this year, our team committed to improve and work to eliminate all major non-conformities (NC-1s). This year, eight of nine NC-1s from last year have been closed out. This is significant progress and confirms that our message of accountability and leading from the bedside is working.

The daily reports back were consistent that our staff was engaged, professional and proud to be representing Kaleida Health and our community. They made note on what a dramatic difference they have seen from previous years, including the support and engagement from our physician partners.  One of the surveyors commented, “Physician engagement at Kaleida Health is unparalleled from anywhere we have been across the country.”

Although this is tremendous news that needs to be celebrated, we are nowhere near the organization that we strive to be. We will now come to expect these types of results and use this survey as yet another launching point to a better tomorrow.

Every member of the Kaleida Health family – physician, nurse, staff, management, volunteer – must continue to make patient-centered care their priority.  We must strive for a perfect patient experience, each and every day.

Annual MeetingAnnual Meeting on Tuesday, October 14, 2014

All physicians are invited to the Medical/Dental Staff meeting on Tuesday, October 14, 2014 at Hotel @ The Lafayette, Marquis de Lafayette Ballroom, 391 Washington Street, Buffalo, NY 14203.

Cocktails and hors d’oeuvres begin at 5:45 p.m.; the business meeting and dinner will begin at 6:30 p.m.

Flu shots will be offered, and IST staff will be available to answer questions.

RSVP with your dinner selection of fish, steak or chicken by Wednesday, October 1, 2014 to the Medical/Dental Staff Office at (716) 859-5501; by facsimile at (716) 859-5592 or by email to

Reflections from the President of the Medical/Dental Staff

The past six months have allowed me to view Kaleida Health through the prism of change. Change is born out of the struggle and desire to improve, and the change that has occurred at Kaleida Health has enabled the medical staff not only to survive, but also thrive. As a medical staff, we are more engaged than ever to ensure that Kaleida Health is a viable and innovative institution in which to practice.

George Matthews, MDWhile we have made progress in several areas, more improvements are necessary. The Medical Executive Committee is committed to enabling every provider to achieve their unrealized potential. This ambition can only be accomplished if the medical staff members work collaboratively with each other, nurses, support staff, administrators, and most importantly, our patients.

The focus on collaboration will strengthen us. Therefore, I ask each member of the medical staff to examine your individual role in order to answer the question “How can I improve Kaleida Health?”

The Medical Executive Committee has already begun work to identify ways of improving Kaleida Health. Specifically, the committee initiated a review of the staff bylaws, and the proposed changes will be offered for critical evaluation to the medical staff shortly. The Peer Review Committee will make changes to the current metrics evaluating provider performance and the Credentials Committee is evaluating staff qualifications to embark upon new therapies and utilize new technology.

While some of the prospective changes will be accompanied by challenges, I anticipate many opportunities as well for, as Frederick Douglass said, “If there is no struggle, there is no progress.” 

I would also like to acknowledge the Chiefs of Service who have thoroughly embraced the concept of change and process improvement. These physicians are often given the difficult task of resolving problems and expediting processes, ensuring that all of our departments function smoothly and deliver excellent care.

I look forward to working collaboratively with you to strengthen and improve Kaleida Health.

The Physician Payments Sunshine Act

The Physician Payments Sunshine Act (Sunshine Act) requires manufacturers of drugs, medical devices and biologicals that participate in U.S. federal healthcare programs to report certain payments and items of value given to physicians and teaching hospitals. The Centers for Medicare & Medicaid Services (CMS) are charged with implementing the Sunshine Act and call it the Open Payments Program.

dollar graphicWith a few exceptions, manufacturers must report ALL remunerations to physicians and teaching hospitals above $10 per payment or $100 in the aggregate calendar year, including the following information:

The Sunshine Act also sets forth separate reporting requirements for research payments, including safeguards to maintain the confidentiality of proprietary information.
Physicians have the right to review their reports and challenge reports that are false, inaccurate or misleading. However, the timeframe for initiating disputes and having data corrected or publicly marked as disputed is extremely limited.

Physicians must have initiated disputes by August 27 to have potentially erroneous data flagged in the initial public release. Physicians can still initiate disputes on 2013 data until December 31, 2014, but it will not be flagged in the public database until 2015. Access the American Medical Association’s full Sunshine Act toolkit for additional information and registration instructions.

Kaleida Health’s Compliance Department amended the Conflict of Interest (COI) forms for physicians to better assess relationships and events that cause risk due to the Sunshine Act. The COI forms will be required every year. Ensure correct and complete disclosure of all COI information to protect Kaleida Health and you from risk.

For additional information on the Sunshine Act, please visit Please contact Robert Trusiak, chief compliance officer, at 859-8053 with questions or concerns.

Abuse Policy Updated

Mandated reporters who work for a school, child care provider, foster care facility, residential care facility, hospital, medical institution or mental health facility, and who have direct knowledge of any allegation(s) of suspected child abuse or maltreatment, must personally make a report to the Statewide Central Register on Child Abuse and Maltreatment (SCR). 

Afterwards, that reporter should then notify the person in charge of the institution about the report. The person in charge is then responsible for all subsequent internal action that must follow such a report, which may include providing follow-up information to Child Protective Services (CPS). 

Medical Staff Attestation - September 2014

By submitting this attestation, I confirm that as a member of the medical staff I have read, understand and will comply with the information included in this email from Kaleida Health.

Fields marked with an asterisk (*) are required.

First Name *
Last Name*
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Five-digit number assigned by Kaleida Health, also known as your dictation number
Kaleida Health Email*
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