Medical/Dental Professionals

Preparing for the Upcoming DNV GL Reaccreditation Survey

We are quickly approaching our DNV GL survey window. Our annual surveys ensure cmoswe are embracing continual improvement, which ultimately benefits the organization and our patients.

This year, the organization will be reaccredited to NIAHO standards and recertified to ISO 9001:2015. Seventeen surveyors will spend 3.5 days at all our hospitals as well as Larkin, the Center for Laboratory Medicine, Oishei Children’s Outpatient Center at Conventus, and additional off-site locations.

To enhance provider and staff understanding of what ISO means, we are launching an “I am ISO” campaign. ISO focuses on creating consistency across the system where it makes sense, using a process approach to ensure quality when developing policies and procedures, and using risk-based thinking to identify barriers to quality patient care.  

Some of our highest risk areas include:

  • Patient Rights – Restraints
    • Familiarize yourself with policy TX.10, which has revised resources, including chemical restraints guidance
    • Non-violent renewals must be revised within 24 hours from original order
    • PRN orders are prohibited. A new order must be obtained for each episode
  • Patient Rights – Consents
    • Ensure all areas of Consent for Bedside Procedure are complete, including proceduralist’s signature, date and time
  • Sedation
    • Pre-sedation assessment must include Mallampati and ASA and documenting prior anesthetic history
    • Post-sedation nursing monitoring q15x3
  • Surgical Services – Operative Report
    • Must be readily available prior to transfer to next level of care
    • All required elements must be documented. If doesn’t apply – must document N/A (there should be no blanks)
  • Med Staff and Surgical Services – H&P
    • Pre-procedure note meets requirement of H&P
    • When the history and physical is completed within 30 days prior to admission or registration, an updated medical record entry documenting an examination for any changes in the patient’s condition must be completed and documented in the patient’s medical record within 24 hours after admission or registration, and prior to surgery or procedure requiring anesthesia services
    • See Department of Health Plan of Correction – Physician Documentation message above

Thank you for your commitment to providing quality care to our patients. We invite you to share your feedback and participate in our quality improvement initiatives.

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