Medical/Dental Professionals

Annual Accreditation Visit Results

Kaleida Health was surveyed by DNV GL Healthcare, our accreditation organization, from October 15 to 18, for our CMS cmosreaccreditation to NIAHO standards and recertification to the ISO 9001:2015 Quality Management Standards. First and foremost, Kaleida Health met our goal of having no repeat non-conformances.

Seventeen surveyors reviewed more than 130 medical records and surveyed everywhere from our hospitals to our clinics to off-site ambulatory locations, and even the back office, in order to evaluate our compliance with federal, state and ISO standards.

The survey team commented throughout the survey how impressed they were to see our progress as an organization, as well as the innovation and care that occurs every day at Kaleida Health.

Here are the non-conformances surveyors identified. Multidisciplinary teams are already actively working on identifying true causes and corrective actions in the following areas:

  • Infection Control & Prevention/Surgical Services: Immediate use steam sterilization without required documented and acceptable reasons for use
  • Medication Management/Nursing Services: Sedation for mechanically ventilated patients without specific parameters for titration
  • Anesthesia Services/Nursing Services/Surgical Services: Pre-sedation evaluation missing required Mallampati assessment; respiratory status not documented during procedure, post procedure level of sedation not documented, sedation discharge criteria not documented prior to discharge
  • Medical Imaging: Protective lead apron inspection overdue/missing
  • Patient Rights (Specific Rights): Missing signed Important Message from Medicare four hours prior to discharge
  • Patient Rights (Restraints): Violent and chemical restraints missing documentation and order requirements per standards; plan of care for restraints missing; prolonged restraint use process not defined in practice/policy; patterns and trends identified for restraint use needs to be more robust
  • Medication Management (Med Orders): Medications given outside of pain scale
  • Life Safety: Penetrations; fire door inspection program (DMH) did not include all required NFPA requirements; lack of medical staff participation in NFPA-required OR fire safety training; storage not in fire-rated room; no annual forward flow test done (MFSH); BGMC fire doors without positive latching
  • Medication Management: Ancillary staff without required medication security training
  • Medication Management/Infection Control & Prevention: Single-dose contrast used as multi-dose (DMH)
  • Patient Rights (Specific Rights, Grievance Procedure): Patient Bill of Rights (copy provided to patients) did not include phone number for who to contact with compliant within hospital; policy only includes inpatients (requirement includes inpatients and outpatients)
  • Medical Records: Chemo infusion orders didn’t include date/time/initials of ordering provider
  • Safety Management: Mislabel of electrical panels and breakers
  • HazMat: Lab staff handling regulated medical waste without required DOT training
  • Medical Equipment: Medical equipment vendors not properly following Kaleida Health’s inspection process before equipment put into use

If you would like to be part of any of the DNV GL NC Design Teams, please reach out to your site quality representative today.

In addition, Kaleida Health was randomly selected for a Department of Health validation survey shortly after our accreditation survey. Our culture of continued survey readiness ensured we were well prepared for the DOH survey, and we appreciate your participation.

David Hughes, MD, MPH
Chief Medical Officer
Kaleida Health

Kenneth Snyder, MD, PhD
Chief Physician Quality Officer
Kaleida Health

Michael Mineo, MD
Chief Medical Officer
Millard Fillmore Suburban Hospital and DeGraff Memorial Hospital

David Pierce, MD, FACEP
Chief Medical Officer
Buffalo General Medical Center/Gates Vascular Institute

Stephen Turkovich, MD
Chief Medical Officer
Oishei Children’s Hospital