Medical/Dental Professionals

Quality and Safety

High Five Hand Hygiene Program

This month, Kaleida Health is launching the “High Five” Hand Hygiene Program to foster a culture of accountability and safety.highfive


Proper hand hygiene is key to preventing the spread of infection in all healthcare settings. The goal of the High Five program is to ensure the best possible healthcare outcomes for our patients.


As part of the program, if a staff member observes another staff member not performing hand hygiene or about to miss an opportunity to perform hand hygiene, he/she can wave their hand or say “high five” to remind their colleague to perform hand hygiene.      


All healthcare personnel (HCPs) are included in this initiative (nurses, physicians, advanced practice providers, environmental services, residents, students, dietary, etc.), and this initiative is fully supported by administration.


Kaleida Health’s expectation is that all healthcare personnel begin every patient encounter by performing hand hygiene. In addition, our policy follows the World Health Organization’s 5 Moments of Hand Hygiene:

  1. Before touching a patient
  2. Before clean/aseptic procedure
  3. After bodily fluid exposure risk
  4. After touching a patient
  5. After touching patient surroundings

If everyone remembers to “foam in/foam out” of patient care, we can help prevent healthcare acquired infections (HAIs) without even an extra thought.


Contact your site’s infection prevention team for additional information.

Flu Vaccination Status Due by November 30

Kaleida Health’s Employee Health is now offering flu clinics across the system throughout November. See KaleidaScope for the Flu Clinic Schedule (must access link from a Kaleida Health computer/while connected to Kaleida Health network).

All healthcare personnel must either receive or decline the influenza vaccine by November 30, 2019.flubug

Providers vaccinated by a facility or provider other than Kaleida Health will need to bring official proof of vaccination to Kaleida Health’s Employee Health Department in order to receive their sticker of verification.

Those who decline the influenza vaccine must complete a “Declination of Influenza Vaccine” form. Anyone who declines the vaccine due to a medical condition will also need to complete the “DOH Medical Exemption Statement” form. Details for both forms are available on Employee Health’s website on KaleidaScope.

Employee Health, or a site designee, will apply a purple sticker on the right lower corner of the Kaleida Health ID badge of those who decline vaccination. Those with a purple sticker must wear a mask in areas where patients or residents are typically present once influenza is declared prevalent in our area.

Kaleida Health’s Medical Staff Office will be tracking providers’ vaccination status. All providers must submit a copy of their proof of vaccination or declination of vaccination to the Medical Staff Office. Please scan and email documentation to Sarah Cecilia at    

OCH NICU Celebrates 500 CLABSI-free Days

The Neonatal Intensive Care Unit team at Oishei Children's Hospital recently reached a major patient safety milestone: 500 CLABSI-free days!

Infections in the bloodstream are a risk for critically-ill infants and children with central intravenous lines for medications and nutrition. Our team of neonatologists, nurses, clinic coordinators, and infection control and pharmacy staff have worked hard to reduce the risk of Central Line Associated Bloodstream Infections (CLABSIs) in our fragile NICU population and has succeeded for 500 consecutive days, a significant accomplishment!

This achievement is the result of collaboration, communication and shared responsibility among physicians, nurses, staff and ancillary teams who work together for the safety of our patients. 

Please join us recognizing the ongoing efforts of our NICU team who work tirelessly to care for our community’s most vulnerable patients! 


Suburban Goes 100 Days CAUTI-free

Congratulations and thank you to the entire Millard Fillmore Suburban team. October 23 marked 100 days without a patient obtaining a CAUTI (Catheter Acquired Urinary Tract Infection) within the hospital!

Going 100 days is a great accomplishment for the hospital and demonstrates the amount of teamwork and focus our clinicians, physicians and ancillary teams have put into decreasing this preventable condition. 

Some of the steps that have been taken recently to reduce CAUTIs include:

  • Increasing awareness around true indications for catheters
  • Removing catheters as quickly as possible
  • Nurse Driven Protocol for removing catheters that is based on real time assessment of patient needs
  • Assessment at the time of transfer out of the ICU for continued need of catheter

Continued vigilance as a hospital team around this safety measure ensures that we are all delivering on our commitment to lead with CARE for the safety of our patients.

Kaleida Health Launches Safe Sleep Campaign to Curb Sudden Unexpected Infant Death Rates

Kaleida Health has launched a Safe Sleep Campaign to help curb Sudden Unexpected Infant Death (SUID) rates.safesleep Last year, 90 infants died of SUID in New York State. 

The campaign includes flyers, informational brochures, education from our clinicians and co-branded Buffalo Bills/Kaleida Health sleep sacks for all families with newborn and neonatal intensive care unit (NICU) patients at both Millard Fillmore Suburban Hospital and John R. Oishei Children’s Hospital (OCH) as well as families with inpatients under one year of age at OCH.

SUID can be greatly reduced by following some simple steps:

  • Place the infant Alone, on their Back in a Crib (the ABCs of Safe Sleep)
  • Sleeping on the back helps to keep the airway clear for breathing
  • No blankets, toys, bumpers, pillows should be in bed with baby
  • Baby should never sleep with parents
  • A sleep sack (as pictured) is a wearable blanket that keeps material away from infant's face

Language Assistance Note: Obtain Waivers of Kaleida Health Interpreter Services

Kaleida Health provides free interpreting services to patients who are limited in English proficiency and their companions involved in their care and medical decision making (Policy #IAC.31). Kaleida Health provides video remote interpreting and over-the-phone interpreting through CyraCom, and face-to-face interpreting by the International Institute and Journey’s End.

When a family member, friend, or Kaleida Health staff interprets medical information for a patient, the patient is required to sign a Waiver of Interpreter/Translator Services (Form KH01004 in Forms on Demand). By signing this, the patient waives the free interpreter services of Kaleida Health.  The waivers are available in many languages, and staff can locate them for you. 

Kaleida Health prefers that patients use its free interpreter services rather than rely on family and friends. It may be difficult for family and friends to be objective in their interpreting, and they may not be familiar with medical terms. All of the Kaleida Health-provided interpreters receive training.

Only one waiver is needed for an inpatient stay, and a waiver signed in the Emergency Department is valid for an inpatient stay resulting from an Emergency Department visit.

Electronic Medical Records (EMRs) are audited quarterly to determine if patients received the free interpreter services to which they are entitled or, if not, if they signed a waiver. A frequent area of non-compliance is family and friends interpreting when there is no waiver. 

Please help Kaleida Health obtain the necessary waivers. If you have any questions, please contact Susan Lankenau, civil rights/language assistance coordinator, at 859-8604 or She is happy to answer your questions, provide education regarding language assistance, review medical records with you, or provide any other assistance in this area. 

Free LGBTQ Sensitivity Training Courses Available Online

Kaleida Health’s hospitals are recognized as leaders in LGBTQ Healthcare Equality by the Human Rights Campaign Foundation. As a leader, Kaleida Health is committed to offering free LGBTQ training to all providers and staff. This free training supplements the Talent Management LGBTQ training.

Providers can choose from more than 50 different online, on-demand, CME/CEU accredited, LGBTQ training options, including interactive eLearning courses and recorded webinars. Courses are offered through The Center for Affiliated Learning and The National LGBT Health Education Center. Topics range from the basics of LGBTQ patient-centered care to more specialized topics for clinicians. Course descriptions are available at  

For example, Expanding LGBTQ Cultural Competency is a four-course series that serves as an introduction to LGBTQ health care, including strategies for delivering accessible and affirming health care. It covers common issues that clients may have and provides basic cultural competency skills for working with LGBTQ clients and colleagues. In full, this series takes up to 90 minutes to complete and is intended for all staff.

All providers are encouraged to take advantage of this training opportunity. To learn more about this opportunity and to register, please contact Susan Lankenau, civil rights coordinator, at or at 859-8604.