Medical Staff Updates - Kaleida Health

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

Message from the President of the Medical/Dental Staff

I was talking to a friend recently about her daughter, who has been battling addiction for almost 10 years. My friend told me that her daughter has lost 19 friends to overdoses in the past two years. Nineteen! That is 19 young people, 19 sons and daughters, whose lives have been cut short by a disease that is targeting them across all parts of our society and all parts of our country.

I am very glad that New York State has recognized this crisis and is providing funds to combat it. Kaleida Health, University at Buffalo and ECMC are working hard to find ways to address the problem. It will require coordination among all of Western New York’s healthcare entities, and it will require continued funding.

Unfortunately, it appears we cannot look to the federal government for help. The proposed Senate version of the House’s healthcare bill devastates Medicaid. Among many other things, Medicaid pays for anywhere from 35% to 50% of addiction services (https://nyti.ms/2sY4229). Cuts in this kind of funding will hurt our most vulnerable citizens and neighbors.

I have asked you in the past, and I ask you again, to join me in fighting for our patients. We must be sure they have access to the care they need and the insurance to pay for that care. Please help by calling your senators and your professional societies. Please help save the lives of our children.

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

Quality – Mock Accreditation Survey Results

At the end of May, Kaleida Health’s ISO Internal Audit Team conducted a two-week Mock Accreditation Survey. Below is a summary of the major areas in which the team identified non-conformities:

Infection Control: Pre-opened patient care supplies (O2 tubing, venti masks not in intact packaging); hand hygiene issues; staff not able to articulate dwell time for equipment cleaning (answer is four minutes for all wipes); ensuring single use items are only used for one patient (IV bags); outside shipping boxes on floor; items resting on floor; equipment with build-up of dust; food and drink found in clinical areas (OSHA regulation); uncovered linen; pre-opened laryngoscope blades (not in intact packaging); clean/dirty mix in rooms; not cleaning equipment per manufacturer’s instructions for use; tape on equipment/walls/windows
Medical Staff – Clinical Privileges: Procedural areas having a process to check credentials (should use Practitioner Search on KaleidaScope)
Medication Management: Medications not secured (including keys hanging, carts unlocked, medications on top of WOWs) and nurses not following insulin double check process
Safety Management: Sharps and chemicals not secured; expired supplies found
Patient Rights: Several findings related to not protecting patient information (screens unattended with patient information visible); printed and unattended patient information, including PLUE stickers
ISO Control of Documented Information: Not utilizing Forms on Demand to access forms at time of use; Documented Information Log incomplete or not present in departments audited (all staff must know where this is); incomplete documentation
Patient Rights – Restraints: Order renewals not being done in a timely manner (at 0930); ensuring appropriate orders (violent vs. non-violent); restraint care plans not being updated
Surgical Services: Ensuring History & Physicals (H&Ps) are in chart prior to surgery; operative reports not complete/not all required elements documented; consents not complete and accurate

April 2017 YTD Financial Update

First four months operating income of $8.0M. Slightly behind plan by $1.5M, in line with 2016 results
Net Patient Revenue of $495M, on plan and slightly favorable compared to 2016
YTD total discharges are on plan and in line with prior year
Inpatient and ambulatory surgical visits behind plan on average by about 4%
Emergency Department visits exceed plan by approximately 2%
YTD total cost per case favorable to budget. CMI slightly favorable to plan
Site leadership and finance teams continually collaborate to ensure achievement of annual targets

Oishei Children’s Hospital Move Update

Oishei Children’s Hospital (OCH) is now 91.46 percent complete
Interior work is progressing, with installations of glass and doors continuing in all areas, as well as final coats of paint and plumbing fixtures
Concrete is being poured around perimeter and some of the landscaping has gone in
Teams have participated in several successful equipment mock moves, with tabletop patient move simulations scheduled in the coming weeks

Unsigned Admissions Orders

All advanced practice provider (APP), resident and fellow orders for IP have to be cosigned by an attending physician with admitting privileges
Free standing (not embedded in pre-procedure note) ASU orders by APPs do not need cosignature
All pre-procedure orders entered by APPs, residents and fellows have to be cosigned by attending surgeon or attending proceduralist (i.e. GI, IR). This note is the responsibility of the attending surgeon or the attending proceduralist (NIAHO SS-6)
All post-procedure notes entered by APPs, residents and fellows have to be cosigned by the attending surgeon or attending proceduralist. This note is also responsibility of the attending surgeon or the attending proceduralist (NIAHO SR-2, SR-3, SR-4)
Operative note needs to be done by the attending surgeon or attending proceduralist, or cosigned if it is done by an APP, resident or a fellow (NIAHO SR-1, SR-4)

Problem and Diagnosis List

What is the Problem and Diagnosis List?

The central place to obtain a comprehensive and concise view of the patient’s medical problems
A "cheat sheet to patient health"
It is the primary means for communicating important aspects of the patient’s ongoing care throughout the entire healthcare continuum

What are the benefits of using the Problem and Diagnosis List?

Best quality care
- Ensures that significant issues that affect treatment decisions are not hidden within the medical note
- Serves as a checklist, especially for complex patients, prompting timely review of all important problems
- Sharing information across disciplines, specialties, pharmacies, hospitals
- Improves collaboration by multiple care providers while managing complex issues/conditions
Decreases documentation duplication – Links/transfers your diagnoses to documentation templates, orders, Rx, discharge instructions
- Supports the “collect once, use many times” principal
Encoded Problem/Diagnosis List - Diagnosis Assistant – Supports accurate documentation, subsequent coding, professional billing, and assigns an ICD-10 code for billing/prior authorization purposes
- Higher diagnosis specificity/acuity = more specific/accurate coding = accurate data utilized for public profiling and reporting (i.e. Leapfrog, CMS VBP, Healthgrades etc.)
Supports medical necessity and medical decision making = reduces payer denials for professional and facility/institution billing
- Accurate documentation and coding serves to justify the services, which are billed and reimbursed
- Coding without having a supporting diagnosis in the chart note can lead to overpayment and risk for both institution and providers
Supports patient safety – Prompts automated clinical decision support
- Can launch clinical alerts, reminders and order sets
Compliance with regulations
- Meaningful Use
- Populates a summary of care record for transitions of care and referrals which should include a problem list
Allows for population management, trended data and treatment, and outcome studies

Allows for accurate identification of disease specific to populations for quality improvement programs, and potential research study participants

Who should use it?

Any clinician who is a member of the patient’s care team
The patient’s attending physician or designee (e.g., resident, fellow, PA, APP) during the inpatient admission and discharge processes
Specialists and primary care providers during the course of ambulatory care
Any clinician while in consultation with the patient’s attending physician
How should it be used?
Adding active problem/diagnoses missing from the list
Changing or modifying problems/diagnoses (refining from generic to more specific diagnoses)
Deleting duplicative or inaccurate problems/diagnoses
Resolving active problems/diagnoses
General Guidelines for the Problem/Diagnosis List
Problem/diagnoses lists are not optional (required by Meaningful Use)
Must be accurate
Must be standardized to ensure that clinical decisions can be made during the patient encounter
Must be updated during every encounter
Must detail the appropriate diagnoses and/or symptoms or findings that warrant current or future encounters
Diagnoses must be refined from generic to more specific as problems become more specific and a diagnosis is made
Must include active problems
Duplicative or inaccurate problems must be deleted from the problem list

Resources Available for Providers

The Clinical Documentation team will come to any department/service line meeting to demonstrate the Problem and Diagnosis List as well as the Diagnosis Assistant. They can also provide at-the-elbow support as you are documenting.

Please contact the resources below to schedule a demonstration or if you need assistance:

Inpatient CDI:

Kathy Kelsey-Morgan, RN, CDIP, Manager Clinical Documentation, 859-1393 or kkelseymorgan@kaleidahealth.org

Outpatient/Professional Billing CDI:

Jeannine Mages, RHIA, CIRRCC, Manager Clinical Audit Process, 859-8293 or jmages@kaleidahealth.org

Amy Yung, RN, CCDS, CDIP, Director Revenue Cycle Clinical Support, 859-8967 or ayung@kaleidahealth.org

EMR Support:

Please contact the Technology Assistance Center (TAC) for any EMR questions at 859-7777. The TAC is staffed with clinical (RN) EMR specialists Monday- Saturday, 6:30 a.m.-7 p.m. On-call resources are available after hours.

There are also two resources on Kaleida Health’s Talent Management including a “Problems and Diagnoses Quick Reference Card” and a 10-minute online class titled, “Diagnosis Assistant.”

Physician Gainsharing Program

Recognizing the important role of physicians in ensuring efficient hospital operations, Kaleida Health established its Physician Gainsharing Program to better align the goals of both the physician and the hospital, improve quality and provide the most cost effective care possible. Participating physicians benefit from the following aspects of the program:
Rewards achieved levels of performance, incentivizes improved performance
Compensates for loss of income for medical admissions
Provides detailed data on individual physician utilization and quality metrics, adjusted for severity of illness
Provides ongoing feedback to physicians
Quality evaluation based on overall performance, not individual cases
Incentive only/no risk or penalties, based on individual performance

At the end of 2016, the Gainsharing Redesign Steering Committee initiated changes to enhance the program, including:

Shift in quality metrics to align with Kaleida Health’s system goals
Quality metrics can be measured and monitored in real time and provide a graduated scale to better incentivize performance and improvement
Cost per case metrics will shift away from AMS and will be tabulated internally using Crimson Continuum of Care
Cost per case metrics can be pushed out to physicians on a monthly basis to identify opportunities within the cycle, allowing participating physicians to maximize their incentive payment

For any questions, please contact Brian Meade at 716-859-7262 or bmeade@kaleidahealth.org.

Paper Prescriptions During an EMR or ePrescribe Downtime

New York State law is such that it is illegal for a pharmacist to fill a script if the name of the provider is not imprinted. Kaleida Health recommends that all providers either retain a small supply of personal prescriptions with one’s name imprinted or purchase a stamper to have readily available in the event of an ePrescribe or EMR downtime.

Leading with CARE Through Empathy 2017

As a reminder, providers are strongly encouraged to participate in this year’s Leading with CARE Through Empathy class. The class is a 30-minute, web-based course available on Talent Management until Tuesday, August 1, 2017.

Cardiology Services Restructures Across Kaleida Health

Kaleida Health recently restructured its Cardiology Services to better serve its patients, provide more standardized care across the organization, improve outcomes, and focus on improved, streamlined services.

Vijay Iyer, MD, PhD, was named medical director of cardiology for Kaleida Health. Dr. Iyer previously served as medical director of cardiology services at Buffalo General Medical Center/Gates Vascular Institute (BGMC/GVI). In his new role, he will be responsible for oversight of cardiology across Kaleida Health, ensuring standardization of practices throughout the system.

Susan Graham, MD, will serve as director of clinical cardiology at BGMC/GVI. Dr. Graham most recently held the role of medical director of cardiac clinical coordination. She will now oversee clinical cardiology services at BGMC/GVI and develop processes, quality and patient care programs.

At BGMC/GVI, Stanley Fernandez, MD, PhD, was named director of noninvasive testing, which encompasses ECG, stress tests, echocardiogram, TEE, nuclear stress and CTAC. Donald Switzer, MD, will continue in his role as director of electrophysiology lab testing, and Kishor Phadke, MD, will also continue to serve as director of cardiac catheterization lab testing at BGMC/GVI.

At Millard Fillmore Suburban Hospital, Michael Banas, MD, was named director of noninvasive testing, and Michael D’Angelo, MD, will serve as director of clinical cardiology.

Christopher Mallavarapu, MD, continues as director of cardiac catheterization lab testing at Olean General Hospital.

Save the Date: Gates Vascular Institute Symposium

Online registration for the Gates Vascular Institute Symposium: Updates in Cardiac, Vascular & Neuroendovascular Medicine will open on August 1, 2017.

This year's event will take place on Friday, October 13, 2017 and Saturday, October 14, 2017. Please note the new location:

The Grapevine Banquets
333 Dick Road
Depew, NY 14043

Visit the Gates Vascular Institute Symposium website for additional details.

Clinical Research: Physician to Study Why Some With HIV Don’t Progress to AIDS

A small percentage of the world’s population — about 1 percent — can be infected with the HIV virus but not progress to AIDS, and researchers do not know why.

Called “long-term nonprogressors,” these people have been studied extensively, but the specific mechanism of their survival remains a secret.

A UB faculty member and researcher has been awarded a five-year, $1.9 million grant from the National Institute of Allergy and Infectious Diseases to look into that mystery.

“People have been studying this population, but there has not been a definitive explanation of why they do well without therapy,” says Mark D. Hicar, research assistant professor of pediatrics in the Jacobs School of Medicine and Biomedical Sciences, and the grant’s principal investigator.

HIV and AIDS research has fallen from the headlines in America, in part because new medicines have helped turn AIDS into a chronic disease that can be managed. But those drugs are expensive and widely available only in the developed world. Across the globe, AIDS is still on ongoing issue, with 40-50 million active infections.

So it remains a global threat.
Hicar, also a pediatric infectious disease physician at Women & Children’s Hospital of Buffalo, is continuing work he started during his fellowship. He is looking into a group of 100 antibodies culled from a group of long-term nonprogressors. From this collection, he has discovered previous uncharacterized targets for antibodies on the gp41 section of the envelope protein on the surface of the virus.

Hicar discovered that, compared to those that progress to AIDS, other populations of long-term nonprogressors are also enriched for antibodies that target these specific sites. It’s possible that antibodies similar to those in his collection are key to how someone becomes a long-term nonprogressor.

Most antibodies help to shuttle viruses and bacteria to other immune cells that gobble them up. The antibodies in Hicar’s collection don’t seem to function in the normal manner of antibodies that neutralize virus. “It isn’t clear precisely how they work,” he says, but finding how they function is another aim of the study.

Hicar is an MD and has a PhD in immunology. As a student, he was interested in the DNA structure of how antibodies are built, and wanted to study the targets of antibodies in infectious diseases.

With the grant, he will study three groups of people with the HIV virus: long-term nonprogressors, regular progressors and people who have recovered while taking medication to discern if targeting these sites truly correlates with long term non-progression.

If Hicar has identified the mechanism that allows people to live with HIV without medication, it could lead to new medicines for people with the virus or even a vaccine. Article written by Grove Potter, UBNow. Published May 8, 2017.

New Providers

Please welcome the following new appointments to Kaleida Health:

Name	Clinical Service	Category or Coll/Super
Aronica, Lynn-Marie, MD	Obstetrics & Gynecology	Associate
Bevilacqua, Thomas, MD	Radiology	Associate
Billitttier, Allyssa R., PA	Emergency Medicine	APP – Sucharita Paul, MD
Chadha, Kunal, MD	Pediatrics/Emergency Medicine	Associate
Cole, Adam J., MD	Radiology	Associate
Dawli, Tamara B., MD	Surgery/Plastic Surgery	Associate
Eckl, Jenna E., ANP	Orthopaedic Surgery	APP – Thomas Lombardo, MD
Eimer, Molly C., ANP	Internal Medicine/Geriatrics	APP – Kenneth Garbarino, MD
Fenire, Mahmoud, MD	Internal Medicine/Hospitalist	Associate
Keller, Craig E., MD	Internal Medicine/Gastroenterology	Associate
Lesh, Kevin C., MD	Family Medicine	Associate
McCloud, Aron K., DO	Pediatrics/Cardiology	Associate
McLaughlin, Maggie J. FNP	Internal Medicine/Cardiology	APP – Ashish Bhatia, MD
Patel, Arpit A., DO	Radiology	Associate
Plouffe, Giovanna, ANP, DNP	Internal Medicine/Hospitalist	APP – Angel Mier Hicks, MD
Rajeswary, Jyotsna, MD	Internal Medicine	Associate
Renda, Julie E., DO	Internal Medicine	Associate
Ricchiazzi, Tina, FNP	Internal Medicine	APP – Vijay Iyer, MD
Whittier, Severine M., CRNA	Anesthesia	APP – George Toufexis, MD
Zahra, Mahmoud, MD	Radiology	Associate

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 apalombo@kaleidahealth.org or 716-859-8447.

Revised Policies:

TX.62 - “Hand-Off” Communication in Patient Care – Documentation was updated throughout and statement E added to procedure

Medical Staff Attestation - July 2017

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.

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