Medical/Dental Professionals

Elevating a Culture of Safety and Quality

In an effort to elevate a culture of safety and quality, Kaleida Health is enhancing the way it reviews cases CHIEF-MEDICAL-OFFICERSand ensures quality improvement.

Within the case review process, site chief quality officers work with their site chief medical officer and physician quality leads to review all case quality inputs. Measures that meet criteria for being publicly reported are analyzed to ensure documentation matches the care and thought process. If there are opportunities for clarification, the site quality team will reach out directly to providers to discuss cases and, at times, ask for clarification and amendments to current documentation. Cases that meet criteria for publicly-reportable measures will be forwarded to the Medical Staff Office and sorted by service line. 

Each chief of service built a quality dashboard, which will be populated with case data. Service line quality leads will review the service line dashboard/case list and determine which cases are best served for M&M, root cause analyses (RCAs) or Professional Practice Evaluation Committee (PPEC) referral.

We also updated and simplified the way we display our quality dashboard as a system as well as on the site level. There are three domains with two categories per domain:

1. Safety
      - Hospital Acquired Infection (HAI)
      - Patient Safety Indicators (PSI)

2. Outcomes
     - Mortalities
     - Readmissions

3. Engagement
    - Patient Experience (HCAHPS)
    - Population Health/CPC+/MIPS

This data is a CMS subset of our patient data representing a 12 month rolling average compared to 2018 year-end results. The data also shows how we compare to the latest national average for each measure. The system goal is year-over-year improvement for every measure.

As we continue to make improvements, we ask for your feedback. For the fourth year, Kaleida Health is seeking input from providers, clinical staff and managers who perform direct patient care through the anonymous and confidential Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture.

The survey will help Kaleida Health assess the current status of its patient safety culture as well as identify strengths and areas for patient safety culture improvement. The goal is to learn how Kaleida Health can improve patient safety, not to get anyone in trouble.

Kaleida Health will assign this year’s survey to appropriate individuals through Talent Management on Monday, April 8. The survey, which takes 10 to 15 minutes to complete, will be open until Friday, May 3. Results will be shared in mid-summer.

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/Gates Vascular Institute

David Pierce, MD, FACEP
Chief Medical Officer
Millard Fillmore Suburban Hospital and DeGraff Memorial Hospital

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