November 2015

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

Medical Leadership Message

Medical LeadersIt has been a busy few months for Kaleida Health's Quality Team.

Leapfrog recently released their biannual safety scores and Kaleida Health has made major improvements.

Buffalo General Medical Center and DeGraff Memorial Hospital received B ratings (up from C) and Millard Fillmore Suburban Hospital was rated C (same as last time). Although Millard Fillmore Suburban remained a C, all three facilities made significant improvements since the last report.

Also, DNV Healthcare Inc., our accreditation partner completed their annual survey, and we are proud to report that Kaleida Health cleared all nonconformities from the previous year.

Although we are pleased with these results, there is still much work to do.

Besides working on the plans of correction for our new DNV nonconformities, we need to work proactively, looking for our own quality improvement opportunities. To drive a culture of continuous improvement, starting this month internal audit teams made up of Kaleida Health providers and employees will visit various departments across the system. This non-punitive process will look for opportunities to improve care and standardize best practices. If you have interest in participating on an audit team please contact Maralyn Militello at

This month we will also implement a standard Morbidity & Mortality process. It includes random chart review and formal reporting within an educational forum. The process clarifies the quality structure and the role of peer review and root cause analysis.

We look forward to working with our providers as we continue to improve the culture, quality and safety for our patients. Quality truly extends across the entire spectrum of care, and every person can make a difference, every day.

At the same time, please do not underestimate the importance of a smile, simply asking someone how they are doing, or if there is anything we could do to help them.

Thank you for leading with CARE.

David Hughes, MD, MPH
Chief Medical Officer
Kaleida Health

Kenneth Snyder, MD, PhD
Vice President, Physician Quality
Kaleida Health

Colin McMahon, MD
Chief Medical Officer
Buffalo General Medical Center

David Pierce, MD, FACEP
Chief Medical Officer
Millard Fillmore Suburban Hospital and DeGraff Memorial Hospital

Stephen Turkovich, MD
Chief Medical Officer
Women & Children’s Hospital of Buffalo

Kamil Alpsan, MD
Site Medical Director
DeGraff Memorial Hospital

A Message from the President of the Medical/Dental Staff

George E. Matthews, MDOn October 8, 2015, the Kaleida Health Medical/Dental Staff held its semiannual meeting at the Park Country Club.

One of the highlights of the evening was a presentation entitled, "Consumerism: Connecting the Dots" by Deborah Reiner, vice president for customer relationship management at HCA Healthcare in Nashville Tennessee. Ms. Reiner's remarks, which are available for viewing, challenged us to appreciate that patient satisfaction and the patient's relationship with a healthcare institution begins prior to the patient entering the facility. Furthermore, the patient experience continues and is influenced by what takes place after the patient leaves.

Attendees also had the opportunity to participate in a live, interactive, real-time results survey. The goal of the questions was to help the Medical Executive Committee (MEC) learn how it can be more responsive to the membership.

The survey results revealed two important points. First, it is imperative that the MEC communicates more effectively about the nature of our work and objectives. Second, the MEC can help foster improved communication between medical staff members and their respective departments. This includes site directors and chiefs of service having an open dialogue about their service line activities, which will impact providing high-quality care in a safe environment.

In an effort to engage more members of the medical staff, Kevin Gibbons, MD, was named chair of the newly formed MEC Nominating Committee. If you know of a member of the medical staff who would help the MEC advocate on behalf of our patients and colleagues, please forward their name to Dr. Gibbons at for consideration. It is essential that we continue to identify individuals who strive for excellence in our medical staff to join the MEC.

It is a privilege to work with the dedicated MEC officers and members, and we welcome any suggestions you have to improve our medical staff.

Physician Engagement Survey Coming

Amplify Your Voice - Physician Engagement SurveyThe 2015 Physician Engagement Survey will be conducted from November 3-17, 2015. Invited physicians will receive an email from Press Ganey after noon on Tuesday, November 3, 2015. Press Ganey will send the email on behalf of David Hughes, MD, MPH, chief medical officer, Kaleida Health that includes a link to the survey.

Kaleida Health's goal is for all invited physicians to amplify their voices and take the survey.

The online survey will only take a few minutes to complete. Please be assured that all surveys are completely confidential. Press Ganey monitors the survey process and will send up to two reminders during the two-week period. Press Ganey does not share who has or has not taken the survey with anyone at Kaleida Health.

Please make sure to complete the survey by Tuesday, November 17, 2015.

The results will be available in late February 2016, and action will be taken in response to the findings starting in March.

Provider Consult Communication

Clear and effective communication is essential to high quality care. On the other hand, inefficient and unclear communication can lead to delays in patient care and frustration including impacting the time spent on a case, errors in care and the quality of consultations.

For example, many providers rely on nurses and secretaries to transmit information that really should be shared directly between providers. Or, consultants may not immediately transmit their thoughts about a case to the referring provider, resulting in lost time. Some providers even transmit patient information by open text or worse, in code, providing an opportunity for misinterpretation.

To ensure timely communication that is fully compliant with HIPAA requirements, the Medical Executive Committee of the Kaleida Health Medical/Dental Staff fully support the use of Imprivata Cortext.

Imprivata Cortext is a secure messaging application that is available for both iOS and Android devices. All information shared through the application is recorded with time stamps, and the application can be turned off when not on duty.

Using Imprivata Cortext and the following communication tips will achieve a higher standard for patient care:

If you no longer have the email from that contained your username, password, and the link to download Imprivata Cortext to a mobile device, please call the Technology Assistance Center (TAC) at 859-7777.

Prescriptions Plus

drugsKaleida Health offers Prescriptions Plus, a program that ensures prescriptions are filled before patients leave the hospital and helps their transition to home.

Available at Buffalo General Medical Center, Millard Fillmore Suburban Hospital and Women & Children's Hospital of Buffalo, Prescriptions Plus not only impacts the convenience with which patients get their prescriptions, the program also increases understanding of medications and improves medication compliance, which helps decrease readmissions.

Prescriptions Plus representatives, who are certified pharmacy technicians, visit with each patient to promote the benefits of the program, facilitate filling of scripts and troubleshoot any insurance coverage issues. The prescriptions are waiting for patients at the on-site pharmacy when they are discharged.

The service is available on all inpatient units, the Emergency Department and for same day surgery patients during the following business hours:

Buffalo General Medical CenterMonday-Friday 9 a.m.-7 p.m.
Saturday 11 a.m.-3 p.m.
Millard Fillmore Suburban HospitalMonday-Friday 9 a.m.-5 p.m.
Women & Children's Hospital of BuffaloMonday-Friday 9 a.m.-7 p.m.

Providers can enroll patients in Prescription Plus by informing the patient's nurse, who will contact the Prescription Plus staff.

Policy Updates for Providers

Below are the new and revised policies and standards of practice that affect providers at Kaleida Health. Please take a moment to review this month's updates. The policy links below are accessible from a Kaleida Health computer only. For additional assistance, please contact Amy Palombo at or 716-859-8447.

New Policies:
ED.1106 – WCHOB Emergency Department Management of Non-Pregnant Patients Greater Than 21 Years of Age

Revised Policies:
MR.19 – Telephone and Verbal Orders – Updated to reflect Electronic Medical Record (EMR) and current acceptable practice

Submit New Content

Is there something you would like featured in an upcoming issue of Medical Staff Updates?

Contact Patty Vorpahl, vice president of Physician Services and Medical Staff Office, at

Medical Staff Attestation - November 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 in accordance with Kaleida Health policy MED.41 as approved by the Medical Executive Committee.

Fields marked with an asterisk (*) are required.

First Name *
Last Name*
Practitioner Number *
Five-digit number assigned by Kaleida Health, also known as your dictation number. To look up your practitioner number, select "Practitioner Search" under Kaleida Links on KaleidaScope.
Kaleida Health Email*

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