Medical/Dental Professionals

Prepare for CMS Re-accreditation and ISO 9001 Re-certification


Kaleida Health, as an ISO 9001 Quality Management-certified organization, is focused on continual improvement. It is imperative that we self-identify problems and develop our own action plans.

For the past 2017, we initiated our own internal mock survey process which resulted in identifying significant nonconformities. Corrective action plans were implemented and many of these issues were corrected. This contributed to a successful 2018 DNV GL survey.

With 2019 being our year for both CMS re-accreditation and ISO 9001 re-certification, we planned a more robust internal survey. Over the course of two weeks, 33 people diligently inspected all areas within Kaleida Health’s acute care sites and several off sites. These surveyors are ISO Internal Auditors and are members of the Kaleida Health family who focused their time and talents to survey different areas of Kaleida Health. We thank them for their time and commitment.

The following themes were identified as areas of improvement:

  1. Cleanliness of areas, including ancillary/support departments outside of clinical inpatient units. Own your work space.
  2. Medication security. Ensure all medications are locked in your work area, especially anesthesia carts.
  3. Post surgical/procedural communication prior to care to care transitions. Documents all required elements prior to transition to next level of care.
  4.  Bedside procedure consent. Continues to have opportunities although improvement in specific clinical areas that were part of other action plans.
  5. Standardization. Many previous action plans were addressed by building and optimizing order sets.  Continue to use and optimize.
  6. Patient rights. Ensure adherence to all policies around patient rights. Special attention around suicide risk and appropriate documentation and ordering of restraints.


David Hughes, MD, MPH
Chief Medical Officer
Kaleida Health

Kenneth Snyder, MD, PhD
Vice President, Physician Quality
Kaleida Health

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

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

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