Medical/Dental Professionals

Quality and Safety

Training Required: Patient Rights for Suicidal Patients

As mandated by CMS, all advanced practice providers and physicians employed by Kaleida Health must complete the Patient Rights for Suicidal Patients training recently assigned on Talent Management titled, “2019 Suicide Training for Providers.”

The course covers the following objectives:

  1. Review regulatory standards related to ligature and suicide risk
  2. Provide a safer setting for patients who are at risk for suicidal ideations that may cause harm to themselves or others
  3. Identify environmental risks
  4. Explain processes to keep our patients and staff safe

The training must be completed within 30 days of assignment.

Training Required: Operative Reports and Discharge Summaries Policy Change

The goal of the Professional Practice Evaluation Committee (PPEC) is to continuously be in compliance with regulations and promote patient safety.

To ensure patient safety, effective September 16, 2019, missing Operative Reports and Discharge Summaries will be combined under one policy: MR.5-Untimely Completion of Operative Reports and Discharge Summaries. All physicians who ever need to compose a discharge summary, operative note or procedure note must complete training about this policy change in Talent Management by September 16, 2019.

The expectation is that patient operative report(s) and discharge summaries be completed within 24 hours of procedure/discharge. These are crucial documents that allow for continuity of patient care.

The New Combined Policy (MR. 5) manages discharge summaries and operative reports in the same manner.

Operative reports/discharge summaries not completed on the day of occurrence will be placed onto AMOK the next day in a YELLOW (delinquent) status. Health Information Management (HIM) will communicate the incomplete documentation to the practitioner via the practitioner’s message center in the Electronic Medical Record (EMR), as well as in email to the practitioner and the Chief of Service (and secretary).

The following day, the chart will automatically turn RED (delinquent) on AMOK if the Operative Report/Discharge Summary has not been completed. If the delinquency continues after 12 p.m., the HIM Coordinator will send an email to the practitioner, Chief of Service (and secretary), site Chief Medical Officer and Medical Records Committee Chair as notification of the practitioner’s continued red status on the AMOK list. All red status practitioners will be tracked and trended by the HIM Department.

For charts with red status on AMOK beyond two days, the HIM Coordinator will send a monthly letter to the practitioner (copied electronically to the Chief of Service, Chief Medical Officer, Medical Records Committee Chair) of the practitioner’s episodes of delinquencies.

AMOK stats are sent to Quality each month, and this information is used for gainsharing incentives.

The Chief of Service, Chief Medical Officer or the Medical Records Committee Chair may request that tracked and trended data be presented to the Professional Practice Evaluation Committee in an effort to communicate with the practitioner. This data will also to be maintained in the practitioner’s Quality file in the Medical Staff Office.

If a practitioner has continued red occurrences on AMOK, they may be required to personally appear before the Professional Practice Evaluation Committee. This is focused on collegial efforts and progressive steps involving communication to resolve deficiencies. The practitioner may also not have an expedited reappointment process when the reappointment time arrives.

Thank you for your cooperation in working with us to complete all operative reports and discharge summaries in a timely manner to ensure patient safety.

Value Analysis - Great Lakes Health Update

Value Analysis is a physician-led process of reviewing products and services for inclusion or continued use within Great Lakes Health. There are five committees including Perioperative, Med/Srg/Lab, CVIRN, Children’s, and Business Services. These committees are charged with reviewing  all products and services requested or in use for quality and outcomes with fiscal responsibility to the organization. Sub-committees are developed to focus on specific initiatives engaging key stakeholders and users from throughout the organization.


Committee Chairs are:

CVIRN – Dr. Kenneth Snyder, co-chair Dr. Maciej Dryjski
Med/Srg/Lab – Dr. Lucy Campbell
Children’s – Dr. Carroll Harmon
Periop – Dr. Thomas Lombardo
Business Services (Non-clinical) – Ed Bauerlein


Key initiatives this month:

    • RFP for Remote Interpreter Service extending access to remote interpreter services optimizing access for patients, clinicians and our Great Lakes of WNY community.
    • RFP for Total Joints/Arthroplasty for all facilities providing these services with high level physician and administration collaboration.
    • PPE standardization – elevating consistency and standardization for safety when selecting products in PPE

Please feel free to reach out to Jacqueline Thompson, RN, director of Value Analysis for any questions regarding value analysis, introducing new products or services and if you would like to introduce a new initiative or would like to actively participate within a committee.