Medical Staff Updates - Kaleida Health

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.

Quality Update: Survey Preparation

Kaleida Health is in its window for the DNV GL survey, which includes certification to the updated ISO 9001 quality management standards. Please help ensure a successful survey by reviewing the following points:

Medication and sharp security: Never leave any sharps, flushes, or medications unattended at any time. NOTE: this is our only repeat finding from our 2015 and 2016 survey
Documentation of language interpretive services in the Electronic Medical Record (EMR): Make sure that when the services are used, it is documented in the patient’s medical record. The Powerform used to document the use of interpretive services is found in the AdHoc Legal folder. In the Emergency Department, this form can also be accessed via a FirstNet Tracking Board icon
Protected Health Information: Keep patient’s health information (in print and on the computer) protected. Make sure to log off computers when not in immediate use
Hand hygiene and personal protective equipment: For anyone passing the threshold of the patient’s door, if on precautions, staff must perform hand hygiene and don personal protective equipment (PPE) even if not touching the patient or surfaces
Documented information control: To ensure you are utilizing the most recent version of a document, they must be obtained at time of use from KaleidaScope (Forms on Demand for a form, such as a consent) and the policy and procedure section for any policies
Life Safety: Do not block medical gas valves, doors, fire extinguishers or electrical panels with equipment. Do not block egress. Any equipment that is plugged in (in hallway) is considered “storage” by a surveyor and could be cited under life the safety fire code
Provider documentation/consents: H&Ps must be available in the chart or done electronically within 30 days of procedure. Consents must be complete (with date/time) and provider performing procedure must sign, date and time provider attestation section. Blood transfusion section must be addressed. Operative notes – all required elements must be present and done prior to patient moving to the next level of care
Maintain integrity of patient care supplies: Do NOT pre-open/pre-spike any items. Once you do, the material loses its integrity in terms of safety and infection control/prevention standards. This includes laryngoscope blades, IV fluids and tubing, etc.
Clean and dirty separation: Ensure clean rooms are kept clean (i.e., no dirty mops, vacuum cleaners, etc.) and vice versa with soiled utility rooms (ensure no clean supplies, etc. are kept in these rooms)
ISO 9001:2015: We are certifying to the new standards during this year’s DNV GL survey. If a surveyor asks who our “customers” are in ISO, it’s our patients! The three fundamentals of ISO include: 1) Consistent care to our patients, 2) Customer satisfaction (to our patients) and 3) Continual improvement of the organization. The model for improvement that we utilize at Kaleida Health is the PDCA action plan (Plan-Do-Check-Act)

Kaleida Health Transitions to Phone, Email and Text Patient Experience Surveys

Last month, Kaleida Health transitioned from a paper-based HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey administered by Press Ganey and invested in a phone-based survey for hospital inpatients and an email and text-based survey for Emergency Departments (ED) and clinics.

The new surveys are administered by HealthStream®, which is one of the leading patient satisfaction measurement and learning companies in the country and works with more than 1,100 hospitals.

To increase patient participation, the phone survey is much shorter than the previous paper-based survey, with only 32 questions including demographics. The email and text surveys are only 10 questions and take a few minutes to complete. The previous paper-based surveys had more than 75 questions.

Randomly selected patients will receive their survey within about two weeks after their visit. Using the new phone, email and text methodology, Kaleida Health will receive patients’ feedback much faster, allowing us to address any concerns in a much more timely manner. Taking action in real-time will help Kaleida Health improve the quality of services and the patient experience.

Register Now: Gates Vascular Institute Symposium

This year's event will take place on Friday, October 13, 2017 and Saturday, October 14, 2017 at:

The Grapevine Banquets
333 Dick Road
Depew, NY 14043

Visit the Gates Vascular Institute Symposium website for additional details.

Save the Date: Medical/Dental Staff Semiannual Meeting on October 19

All Kaleida Health physicians and advanced practice providers are invited to the Medical/Dental Staff Semiannual Meeting on Thursday, October 19, 2017, at Templeton Landing in Buffalo.

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

Additional details will follow.

Kaleida Health Standards of Appearance Policy Changes

As part of the revised Kaleida Health Standards of Appearance policy (HR.21), lanyards are no longer allowed. The identification badge must be worn and clearly visible at the lapel level. To obtain a Leading with CARE badge reel/clip, please visit your site’s administration office.

Work Place Safety Web-based Training

To ensure individuals across Kaleida Health are prepared for all emergency situations, providers are encouraged to watch two videos focused on workplace violence and dangerous/threatening person response, which are available on Talent Management.

The first video of the series, “Flash Point,” illustrates how to recognize and respond to the signs/symptoms of a fellow staff member, patient or visitor who is displaying alarming or unusual behavior within a Kaleida Health facility or on its property.

The second video titled, “Emergency Response for Dangerous Person(s) or Dangerous Situations,” demonstrates the steps to take in the event that an individual is engaging in violent behavior.

To access the curriculum on Talent Management, either click on Talent Management on the Kaleida Links section of KaleidaScope, or go to www.kaleidatms.com and log in using your user name of 3 letters followed by 3 numbers, preceded by ‘kaleida\’ such that the user name is entered as “Kaleida\[3 letters followed by 3 numbers]” and your network password. Then select “2017 Workplace Violence and Dangerous/Threatening Persons” in My Action Items.

LGBTQ Training Available

To continue providing a friendly environment where all patients, families, visitors and staff feel safe and welcome, Kaleida Health is offering training titled, “Serving Our LGBTQ Patients” to its medical staff. The training, which can be accessed through Talent Management, offers general information on lesbian, gay, bisexual, transgender and questioning (LGBTQ) patient-centered care. It should take approximately 10-15 minutes to complete. healthstreamyouropinionmatters

As a participant in the Human Rights Campaign Foundation’s Annual Healthcare Equality Index, Kaleida Health is also offering additional free LGBTQ training to its providers.

Providers can choose from more than 50 different online, on-demand, CME/CEU accredited, LGBTQ training options, including interactive eLearning courses and recorded webinars. Topics range from the basics of LGBTQ patient-centered care to more specialized topics for clinicians.

Course descriptions are available at http://www.hrc.org/hei/training-in-lgbtq-patient-centered-care. To learn more about this opportunity and register for training, please contact Danielle Becker at dbecker@kaleidahealth.org.

By participating in LGBTQ training, providers can help Kaleida Health promote equitable and inclusive care for our LGBTQ patients and their families.

Prescriptions Plus and TransitionCare: Closing the Care Gap

Kaleida Health’s outpatient pharmacies are working to improve patient outcomes through their innovative transitions of care programs, Prescriptions Plus and TransitionCare. The outpatient pharmacies are located within Buffalo General Medical Center/Gates Vascular Institute, Millard Fillmore Suburban Hospital and Women & Children’s Hospital of Buffalo. These programs are providing patients with a smoother transition of care, significantly less readmissions, and overall, a more positive Kaleida Health experience.

Prescriptions Plus is Kaleida Health’s comprehensive discharge dispensing program. As part of the program, each hospital floor is equipped with an Engagement Fulfillment Representative (EFR), who engages patients and offers bedside delivery of medications 15 minutes before discharge, and patient education.

Patient’s medications are filled by a discharge pharmacist who works to make interventions of many types—clinical, financial, and continuity of care. The pharmacist verifies discharge medications as appropriate, affordable, and preferred for each patient. Once the medications are approved, they are filled and delivered to the patient’s bedside by the EFR.

In order to address any fragmentation of care, Kaleida Health’s pharmacies forward a communication form to the patient’s home pharmacy. This informs their home pharmacist that a mutual patient has been discharged and includes the patient’s reconciled discharge medication list; this effectively closes the care gap between the patient’s home and hospital care teams.

TransitionCare provides long-term care, follow-ups, and ongoing continuity of care initiatives.

At the High Street Pharmacy, the pharmacist team reviews the Electronic Medical Record (EMR) for each discharge patient that received medications through Prescriptions Plus. High-risk cardiac patients are identified and flagged for a TransitionCare intervention. These patients receive a follow-up call three to seven days after discharge to provide additional counseling, review of adverse events, and supervision of patient follow-up adherence. When necessary, the pharmacy can call and coordinate outpatient lab work and follow-ups on behalf of the patient.

Now in its second year, TransitionCare has become a proven transition of care program, providing a smoother transition of care, statistically significant decreases in readmission rates, and increased patient satisfaction.

TransitionCare is currently in development at our other locations.

To learn more, visit the Pharmacies’ website.

Clinical Research: Cerebrovascular Disease

UBNS is a world-leader in the prevention and treatment of cerebrovascular disease. Common types of cerebrovascular disease include stroke, aneurysms, and arteriovenous malformations, and clinical trials are an important component to our leadership. The results of clinical trials help determine the safest and most effective medical therapies, and shape the development of the next generation of medical treatments.

UBNS actively participates in four types of clinical trials, which represent a major component of their overall research program: Investigational Device Exemptions (IDEs), Humanitarian Device Exemptions (HDEs), Post-market Approval (PMA), Physician-Sponsored. Currently, UBNS is enrolling patients in a multitude of clinical trials that treat a gamut of neurological disorders.

The VITAL (Volumetric Integral Phase-shift Spectroscopy (VIPS) for the Noninvasive Detection of Hemispheric Bioimpedance Asymmetry in Severe Brain Pathology) study is a non-significant risk device observational study that aims to assess the ability of the CMS-5000 Fluids Monitor to detect the presence of hemispheric bioimpedance asymmetry in severe brain pathology. This device measures the fluid composition of a volume of tissue measured through non-contact electromagnetic induction to detect and quantify tissue changes. Successful detection of bioimpedance asymmetry may allow for the potential for stroke patients to bypass primary stroke centers for thrombectomy-capable stroke centers. This would result in a faster time to recanalization, a key factor in functional independence following large vessel occlusion. The device may also allow for bedside monitoring to detect the early stages of cerebral edema and bleeding.

New Providers

Please welcome the following new appointments to Kaleida Health:

Name	Clinical Service	Category or Coll/Super
Alwakkaa, Hisham, MBBS	Radiology/Pediatric Radiology	Fellow/Accredited
Bacher, Henry M., MD	Emergency Medicine	Associate
Basra, Satraj, MDD	Internal Medicine/Sports Medicine	Associate
Camposeo, Nicholas J., DO	Emergency Medicine	Associate
Carletta, Katherine M., ANP	Internal Medicine	APP – Steven Buslovich, MD
Filipescu, Radu, MD	Pediatric Surgical Services	House Physician
Gable, Ethan, MD	Obstetrics & Gynecology	Associate
Gopinath, Anupama, MD	Anesthesia	Associate
Kenyon, Mark A., MD	Pediatrics	Associate
Martinic, Luke, PA-C	Orthopaedic Surgery	APP – Edward Simmons, MD
Messina, Bridget, MD	Pediatrics	Associate
Monaco, Brian A., MD	Emergency Medicine	Associate
Nowak, Brittany T., PA-C	Internal Medicine	APP – Vijay Iyer, MD
Orellana, Maria, MD	Family Medicine	Associate
Rasul, Samad, MD	Internal Medicine/Critical Care	Associate
Russell, Joshua S., MD	Psychiatry & Behavioral Med/Child Psychiatry	Associate
Shamaa, Aman, PA	Internal Medicine	APP – Barinder Chana, MD
Siudzinski, Thomas R., PA	Internal Medicine/Cardiology	APP – Vijay Iyer, MD
Weeks, Joshua, PA-C	Orthopaedic Surgery	APP – William Wind, MD
Zhulovchinova, Gita, FNP	Internal Medicine	APP – Barinder Chana, MD

Policy Updates for Providers

Below are the new and revised policies 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 apalombo@kaleidahealth.org or 716-859-8447.

New Policy:

PED.44 – Kaleida Health Adult Facility Pediatric Policy

Revised Policy:

MED.42 – Fringe Benefits for Employed Physicians of Kaleida Health – Changes to Disability and Workers’ Compensation

IAC.26 – Social Media Guidelines for Workforce Members – Revisions throughout including being responsible for what you post, not posting pictures, and use of Kaleida email address

IAC.29 – Communicating with Deaf/ Hearing Impaired – Revisions throughout regarding location of tablets, removing PO process, etc.

IAC.31 (was PT.9) – Language Assistance Plan – Revised to remove PO process, add to complaint process, and documentation

TX.10 – Restraints and Seclusion – Rewritten, table added at the end

Medical Staff Attestation - September 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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