April 2015

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

Medical Director Message

After a record breaking winter, spring is finally here. As we look forward to warmer weather, we can also look forward to the continued changes occurring across Kaleida Health that will improve operations, patient outcomes and the organization’s culture.

Kaleida Health launched the Leading with CARE initiative for all employees, volunteers and providers. The two-hour, instructor-led educational session is design to positively impact patient satisfaction, improve employee and physician engagement, and enhance quality.

Jamal Ghani, system chief operating officer, introduced the initiative on March 12 to Kaleida Health’s management team, capturing the emotions and attention of the audience. On March 25, employees began attending the first Leading with CARE sessions across Kaleida Health.

As momentum for this initiative continues, we are confident it will improve the patient experience. If everyone on the healthcare team embraces and commits to CARE, we will improve quality and patient satisfaction. Kaleida Health has all the necessary ingredients for this initiative, and by combining our excellent services, skills, resources and talent, we can and will be successful.

Please monitor your Kaleida Health email account for an invitation to register for an upcoming session through Talent Management.

Led by David Hughes, MD, MPH, chief medical officer, Kaleida Health also launched a new Quality Dashboard, which displays real-time quality metrics on the login screen of all Kaleida Health computers, including Emergency Department wait times, midnight census, patient experience (HCAHPS) inpatient “rate hospital” percentile ranking,  readmissions, and discharged average length of stay.

By knowing these measures and Kaleida Health’s goals, every provider can impact these measures and continually seek opportunities to improve the quality of care.

To further improve quality and physician engagement, Kaleida Health recently reestablished the System Utilization Committee and site-specific sub-committees, which will help improve length of stay and reduce utilization costs in a variety of service lines.

The AMOK process, a patient safety and quality initiative that launched in 2013, continues to be an absolute success as well. When the project first began, the list of overdue medical records was substantial, but thanks to a better awareness of complete documentation, the list is minimal.

As Kaleida Health continues to improve its culture and quality of care, let us all focus our efforts on improving quality, increasing patient satisfaction and, most importantly, leading with CARE.

Kamil Alpsan, MD
Site Medical Director
DeGraff Memorial Hospital

New Vision, New Future

Mission & VisionTo propel Kaleida Health forward and further establish it as the preeminent healthcare organization in the region, Kaleida Health’s leadership team reevaluated the organization’s mission and vision statements to better reflect Kaleida Health’s new direction and culture.

The mission statement remained the same and explains why Kaleida Health exists: To advance the health of our community.

The updated vision statement summarizes the future plans of Kaleida Health: To provide compassionate, high-value, quality care, improving health in Western New York and beyond, educating future health care leaders and discovering innovative ways to advance medicine.

In the coming weeks, providers will notice Kaleida Health’s mission and vision statements prominently displayed throughout each facility as a reminder to ourselves and every person who walks through the doors of our commitment to CARE.

Semiannual Meeting on April 14

As a reminder, the Medical/Dental Staff Semiannual Meeting will take place on Tuesday, April 14, 2015, at Salvatore’s Italian Gardens Restaurant, 6461 Transit Road, Depew, NY 14043.

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

At the event, James Merlino, MD, president and chief medical officer of the strategic consulting division of Press Ganey, will speak about the patient experience in a value-based world.

Dr. Merlino joined Press Ganey in 2015. As an accomplished surgeon and industry leader in improving the patient experience, Jim draws from more than two decades of health care experience to oversee Press Ganey’s consultancy division. Prior to joining Press Ganey, Jim served as chief experience officer and associate chief of staff at the Cleveland Clinic health system, as well as a practicing staff colorectal surgeon at the organization’s Digestive Disease Institute. 

Change in Surgical Attire

nurseKaleida Health is committed to providing exceptional care to patients in a safe environment. Following a recent New York State Department of Health Survey, Kaleida Health’s clinical leadership team decided to remove the blue surgical caps with ties from our surgical attire and replace them with disposable blue bonnets.

The disposable bonnets, along with providers’ diligence to ensure no hair is exposed, promote the best infection prevention strategies in surgical services.

Kaleida Health is in the process of revising its surgical attire policy to reflect updated surgical attire guidelines for head coverings, scrubs, jewelry, masks, backpacks or luggage, and electronic devices. A final copy of the policy will be shared with providers when available.

Electronic Prescribing

eprescribingAll Kaleida Health providers received a special edition of the Medical Staff Updates on Tuesday, March 17, 2015, about electronic prescribing.

As a reminder, despite the delay of the New York State mandate to electronically prescribe all substances, including controlled substances, until 2016, Kaleida Health began electronic prescribing of controlled substances on March 23, 2015.

In order to electronically prescribe a controlled substance, providers must use two-factor authentication. Please refer to the March 17 Medical Staff Updates email for additional details and instructions.

Updates from the Medical Executive Committee

Policy Updates for Providers

As a way to keep providers informed about new and revised Kaleida Health policies and standards of practice that affect their work, Medical Staff Updates will now include a section of policy updates each month.

Please select this link to review full descriptions of this month’s updates. The policy links below are accessible from a Kaleida Health computer only. For additional assistance, please contact Amy Palombo at apalombo@kaleidahealth.org or 716-859-8447.

New Policies/ SOP:
ADM.22 – Image Recording for Medical, Legal, Teaching or Research Purposes
MED.16 – Nurse Practitioner Collaborative Relationships

Revised Policies/ SOP:
HR.211 – Fringe Benefits for Employed Physicians of Kaleida Health
LB-POC.C – Physician Performed Testing (PPT)
LE.5 – Code of Conduct and Business Ethics
LE.10 – Treatment of Unemancipated Minor
MED.6 – Impaired Provider
MED.9 – Disruptive Medical Staff Member Policy
MED.19 – The Aging Provider Policy
MED.26 – Credentialing Reappointment and/or Renewal of Privileges
MED.35 – Medical Staff Peer Review Committee (PRC)
MR.5 – Suspension Process for Missing Final Procedural Reports
MED.29 – Composition of the Credentials Committee
SS.51 (was CL.54) – Verification of Correct Patient, Procedure, and Surgical Site

Medical Staff Attestation - April 2015

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

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Five-digit number assigned by Kaleida Health, also known as your dictation number
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