September 2015

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.

Medical Leadership Message

Chief Medical Officers

As Kaleida Health continues on the journey to transform the way we care for our patients and their families, each day we are seeing and hearing examples of providers and employees who consistently lead with CARE. Many of you have noted the palpable positive culture change throughout the organization. Our patients are feeling the change as well. In the Emergency Departments and inpatient units, more and more patients are reporting that they "always" receive the best care. Patients are also sharing more positive experiences in their survey comment section.

The steady improvement is evident in the significant overall patient experience score improvements, with Kaleida Health moving from the 5th percentile in December 2014 to the 40th percentile in July 2015. This is a testament to the outstanding care you provide at the bedside, and the well-coordinated, efficient care teams that you lead.

Thank you for bringing innovation and excellence to our patients and our organization each day. If you have not already done so, please sign up for a Leading with CARE one-hour session. Your ongoing commitment will continue to fuel the cultural transformation and ensure success. Together we can build a healthier Western New York and set a new standard of care for our region and beyond.

David Hughes, MD, MPH
Chief Medical Officer
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

Special ICD-10 Edition of Medical Staff Updates

The transition from ICD-9 to ICD-10 for reporting diagnoses and procedures on October 1, 2015, is quickly approaching. All Kaleida Health providers received a special edition of the Medical Staff Updates on Monday, August 24, 2015, about ICD-10.

ICD-10 logoThe key to success transitioning to ICD-10 is providers documenting completely and with greater specificity. By being aware of what needs to be in the documentation, providers can ensure proper codes are applied and avoid any financial and regulatory non-compliance repercussions.

As a reminder, on-site Electronic Medical Record (EMR) training for providers begins Tuesday, September 1, 2015.

Semiannual MeetingSemiannual Meeting on October 8

All physicians are invited to the Medical/Dental Staff Semiannual Meeting on Thursday, October 8, 2015 at Park Country Club, 4949 Sheridan Drive, Williamsville, NY 14221.

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

The event will feature guest speaker, Deborah M. Reiner, vice president for Customer Relationship Management for HCA Healthcare based in Nashville, TN. HCA owns and operates 168 hospitals and 118 freestanding surgery centers in 20 states and the United Kingdom.

Reiner is accountable for consumer-facing encounters across the organization. Her passion for the patient experience is her driving force and singular objective. In particular, as a non-clinician, she focuses on continuum-of-care scenarios insisting that the healthcare industry interact with the patient on his or her terms.

RSVP with your dinner selection of steak, chicken, fish or vegetarian by September 25, 2015, to the Medical Staff Office at 716-859-5501; by facsimile at 716-859-5592 or by email to

Leading with CARE Update

Leading with Care logoHave you committed to lead with CARE? The educational sessions offer a simple but powerful reminder to always provide an exceptional patient experience.

View the schedule of provider Leading with CARE sessions being offered and sign up on Talent Management, Kaleida Health's online learning system. To access your Talent Management account:

1. Go to
2. Enter your Kaleida Health network user ID and password, and select sign in
3. See the To-Do List for assigned trainings or search "Leading with CARE"

If you need assistance accessing Talent Management, call the Technology Assistance Center (TAC) at 859-7777.

Sepsis Alerts in EMR

Sepsis is a common and serious medical emergency that results from the body's systemic inflammatory response to overwhelming infection. It is associated with a high risk of morbidity and mortality that can be reduced with early recognition and early goal directed therapy.

On Tuesday, September 1, 2015, Kaleida Health is implementing a proactive risk identification system, St. John Sepsis Agent, in the Electronic Medical Record (EMR) to reduce sepsis cases through early detection.

St. John Sepsis Agent gathers patient data and discerns patterns to alert users of potentially septic patients. EMR users will receive Clinical Decision Support Alerts when the system finds:

• Systemic Inflammatory Response Syndrome (SIRS) Alert - Three signs of SIRS
• Sepsis Alert - Two signs of SIRS plus one sign of organ dysfunction

To ensure early recognition and rapid treatment for sepsis, the Rapid Response Teams at DeGraff Memorial Hospital, Millard Fillmore Suburban Hospital and Women & Children's Hospital of Buffalo will receive sepsis alerts directly to their pagers. The Transfer Center will receive these pages for Buffalo General Medical Center to facilitate rapid triage and notification of the provider.

The alerts are in accordance with New York State Public Health Law and an extension of Kaleida Health's current evidence-based protocols that address early recognition and rapid treatment of sepsis, severe sepsis and septic shock in both the adult and pediatric populations:

Adult Sepsis Protocol
Pediatric Sepsis Protocol

Talent Management education entitled "2015 Sepsis Update," was assigned to all appropriate staff.

Gates Vascular Institute Symposium – Register Now

GVI Symposium logoRegister by September 15, 2015, for the second annual Gates Vascular Institute Symposium: Updates in Cardiac, Vascular & Neuroendovascular Medicine.

This year’s educational symposium will be held Friday, October 2, 2015 (full day) and Saturday, October 3, 2015 (half day).

The agenda, speakers, topics and registration information is available at

Restraints and Consents FAQs

Kaleida Health continues to focus on compliance with restraints and consents to ensure safe, quality care. Please review the frequently asked questions (FAQ) to understand Kaleida Health’s policies and processes regarding the proper use of restraints and obtaining informed consents:

Restraints FAQ
Consents FAQ

PATH Documentation

The Centers for Medicare and Medicaid Services (CMS) guidance for PATH documentation (Physicians at Teaching Hospitals) states that the teaching physician is responsible for preoperative, operative and post-operative care for the patient.

In order to bill for surgical procedures, the teaching physician must be present during all critical and key portions of the procedure and immediately available to furnish services during the entire procedure. The teaching physician presence can be documented as follows:

1. If the teaching physician dictates the procedure note and a resident takes part in the procedure, the teaching physician includes his/her presence as part of the procedure note; OR
2. If the resident dictates the procedure note, the resident should note that the teaching physician was present throughout or during key portions of the procedure (e.g. Dr. X was present and supervised the entire procedure); OR
3. If the resident dictates the procedure note and forgets to document the teaching physician's presence, the teaching physician adds an addendum to the resident's dictation attesting to his/her presence.

Failure to document the teaching/supervising physician's presence will result in rejection of the surgical claim for payment.

Clear documentation regarding the presence of the teaching/supervising physician during procedures also verifies that proper resident oversight is occurring.

Medical Record Discharge Summary Policy Changes

Kaleida Health's Peer Review Committee is committed to ensuring the discharge summary is posted in a patient's medical record within 24 hours of the patient's discharge. To achieve this goal, the Committee is working to revise the medical records policy.

In the revised process, the current thirty day grace period to complete discharge summaries before disciplinary action can be taken will be shortened. Progressive discipline for the provider responsible for completing the discharge summary will be instituted, and the status of discharge summaries for all inpatient and observation patients will be posted on All Medical Records Overdue at Kaleida Health (AMOK), the electronic application that tracks the current status of medical provider documentation completion.

By mid-September, in anticipation of the revised process, the Health Information Management (HIM) Department will pilot tracking the timeliness of discharge summary document completion.

In preparation for this change, all providers are reminded that attendings of record at the time of discharge are responsible for completing the discharge or death summary within 24 hours of the patient's discharge. It is the responsibility of the attending of record to place a transfer order if another attending is assuming care of a patient. Absent the transfer order, the attending of record will be the attending needing to complete the discharge summary.

Please contact Vickie Trautman, director of health information, at with any questions.

Free CME Training in LGBT Patient-centered Care

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:
CL.11 – Management of Critically Ill Patients Greater than 21 years old at WCHOB
MED.24 – Tele-medicine at DeGraff Memorial Hospital

Revised Policies:
SS.1 – Surgical Attire – Policy was mostly rewritten

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 - September 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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