August 2016

Below are the August Medical Staff Updates. As a reminder, all providers must complete the attestation at the bottom of this page by August 31.

Medical Leadership Message

Medical Leaders

Moving into the second half of 2016, Kaleida Health is celebrating several successes in quality/patient safety and patient experience. In 2016, we raised the bar and are holding ourselves to a higher standard to eliminate hospital-acquired infections and conditions, and provide our patients with the absolute best patient experience. Many physician leaders have partnered with nursing leaders to identify root causes and standardize and implement best practices across the organization. We are focused on sharing lessons learned and proactively identifying high-risk areas and practices in order to keep our patients safe.

In 2016, Kaleida Health saw a decrease in four of the six hospital-acquired infections from 2015:

Teams continue to work through opportunities with CAUTIs (Catheter-Associated Urinary Tract Infection) and MRSA bacteremia infections. CAUTIs have increased from 1.7 to 2.1, and MRSA bacteremia’s have remained unchanged from 2015 at 0.1.

The CAUTI team has implemented several tactics to eliminate CAUTIs. One proven tactic is to reduce the use of Foley catheters. Thus far in 2016, we have had 138 less Foley days compared to this time in 2015.

Other quality successes include:

In the pediatrics and adult Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, Kaleida Health saw increases in every domain YTD over 2015. Eighty four percent of adult inpatients rate their experience at an 8, 9 or 10. In pediatrics, 86 percent rate their experience as an 8-10. Throughout Kaleida Health, over 90 percent of inpatients would probably or definitely recommend our hospitals to a friend or family member.

As we pause to celebrate, we also look forward to continuous improvement and engagement. It is through your partnership and leadership at both the bedside and throughout the organization that we will set the standard for both quality and patient safety in Western New York and beyond.

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

Message from the President of the Medical/Dental Staff

Peter Winkelstein, MD, MS, MBA, FAAPA recurring theme at our Medical Executive Committee meetings is how to promote and improve our culture of safety.
What is a culture of safety? It is a commitment to safety from everyone and at all times. The Agency for Healthcare Research and Quality (AHRQ) says there are several key features of organizations with a strong commitment to a culture of safety (

The Institute for Healthcare Improvement (IHI) describes a culture of safety where “people are not merely encouraged to work toward change; they take action when it is needed. Inaction in the face of safety problems is taboo, and eventually the pressure comes from all directions — from peers as well as leaders.” (

Your elected representatives on the Medical Executive Committee are deeply committed to promoting and improving the culture of safety at Kaleida Health. We expect every member of the Medical/Dental Staff to be focused on safety and willing to participate in efforts to improve it. We will work diligently with our partners in administration to give our patients the safest and highest quality care.

Peter Winkelstein, MD, MS, MBA, FAAP
Medical/Dental Staff President
Kaleida Health

Register Now for an Upcoming Leading with CARE Class

Leading with Care LogoThis year's Leading with CARE classes are now underway, and all employees, providers and volunteers must participate in a one-hour, instructor-led class focused on creating a culture of safety using the concept "See, Say, Do."

Each session will be led by a variety of specially-trained facilitators from across Kaleida Health and will offer much more opportunity for group discussion and interaction. Providers should enroll for one of the sessions as soon as possible via Talent Management at

CAUTI Prevention

Part 1 - STOP! Does Your Patient Really Need a Urinary Catheter?

The Catheter-Associated Urinary Tract Infection (CAUTI) team has updated the urinary catheter policy to mirror the insertion indications published by the Centers for Disease Control and Prevention (CDC). Based on the CDC and best practice hospitals, the only acceptable indications for the insertion and for the continuation of urinary catheters include:

The Electronic Medical Record (EMR) team will be updating the indications on the insertion order as well as the existing order sets. Further communication and education for nursing and the medical staff is in progress. As a Kaleida Health medical staff member, we need you to lead in the care of your patients by endorsing only these indications for urinary catheterization. 

Look out for “Part 2 – Do We Need to Order a Urine Culture?” next month.

Register Now – Gates Vascular Institute Symposium

GVI Symposium LogoRegistration is now open for the third annual Gates Vascular Institute Symposium: Updates in Cardiac, Vascular & Neuroendovascular Medicine.

This educational symposium will be held Friday, October 14, 2016 (full day) and Saturday, October 15, 2016 (half day) at Templeton Landing in Buffalo.

This year’s symposium will offer a wide range of speakers, topics and continuing education credits.

Register online before September 1 to SAVE! For more information, visit

2016 Press Ganey Engagement Survey Coming September 1-22, 2016

Engagement Survery PosterWe’re listening, so take the 2016 Press Ganey Engagement Survey, which will be conducted from September 1-22, 2016.

Invited physicians and residents in program year 2 or higher will receive an email from Press Ganey with a survey link on Thursday, September 1, 2016, to their email address. If there is no response, the reminder emails will go to the alternate email, if available. Since we cannot control "spam" to non-Kaleida Health email addresses, recipients should check their spam folders for the link. The sender will be "Press Ganey on behalf of David Hughes, MD."

The online survey will take less than 10 minutes to complete and is completely confidential. Kaleida Health's goal is for all invited physicians and residents to take the survey.

The results will be available by the end of 2016, and action will be taken in response to the findings starting in early 2017.

Save the Date – Medical/Dental Staff Semiannual Meeting

All Kaleida Health physicians and advanced practice providers are invited to the Medical/Dental Staff Semiannual Meeting on Thursday, October 13, 2016, 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.

Watch your Kaleida Health email for an invitation to the dinner via Microsoft Outlook calendar. Please either “Accept” or “Decline” the invitation, and if you plan to attend, please visit the Survey Monkey link within the invitation to select your meal choice.

Ensuring HIPAA Compliance

Please remind your office staff to exercise care when providing patient demographic information to Kaleida Health’s scheduling staff by ensuring the accuracy of the information provided. This is especially important when you have patients with the same or similar names. Kaleida Health’s staff relies on the information your office provides when scheduling and pre-registering the patient. There have been several instances recently where Kaleida Health staff contacted the incorrect patient based on information provided by physician offices. Contacting the incorrect patient puts our staff in a very awkward position and puts them at risk for causing a HIPAA breach. Your assistance in ensuring that the correct information is always provided will be greatly appreciated.

Medical Executive Committee - Department Presentations

Policy Updates for Providers

Below is a revised policy that affects providers at Kaleida Health. Please take a moment to review this month's updates. The policy link below is accessible from a Kaleida Health computer only. For additional assistance, please contact Amy Palombo at or 716-859-8447.

Revised Policy:

CL.4 – Sedation for Operative and Invasive Procedures – Updated to add the last section that medical directors perform audits

Medical Staff Attestation - August 2016

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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