An Important Message From Our CEO
By Gary Herbst, Chief Executive Officer
We have recently learned that the California Department of Public Health
(CDPH) is citing and fining Kaweah Delta Medical Center for an incident
that occurred back in 2018 when a guide wire was inadvertently left inside
a patient following the insertion of a Vascath catheter to support hemodialysis.
Fortunately, the retained guide wire was discovered by x-ray and removed
soon after the procedure, resulting in no harm to the patient. Separately,
and of no correlation, CDPH is also citing us for failing to maintain
a staffing ratio of one nurse to four patients on our telemetry units
in March and April of this year.
You may hear or read about these incidents from local media in coming days,
so we wanted you to know what we are doing to ensure quality of care and
patient safety at Kaweah Delta.
I assure you that as a Medical Center, and a place where our patients look
to us for healing and proper medical treatments, we have responsibly reviewed
these cases in depth at the highest levels of our organization to prevent
future occurrences. The incident involving our patient was an isolated
medical error. When we became aware of it, we immediately removed the
guide wire and promptly reported it to CDPH. The patient was not harmed.
Whether in our operating rooms or at the bedside, we have very strict
policies, practices, and procedures to adhere to patient safety; this
was an unfortunate instance where we did not follow our policies. We have
conducted a careful and immediate study of the incident, reviewed policies,
provided staff with intensive training, and throughout the year, performed
audits and additional training as needed to ensure that we are providing
the highest levels of safe, effective and compassionate care to every
patient. We are always working to provide the highest level of patient
care because it is the right thing to do for our community.
I assure you that there is no correlation between understaffing and adverse
events at our Medical Center. Kaweah Delta is not alone in its struggles
to meet California’s strict nurse to patient ratios. California
is the only state in the nation that is required to be in compliance with
nurse to patient ratios at all times. Nationally, and in the San Joaquin
Valley, hospitals are working to overcome the nursing shortage. We do
everything we can to fully staff every unit to meet nurse to patient ratios.
However, the reality is that we consistently have nearly 70 vacant RN
positions that we are actively recruiting to fill. During the last fiscal
year, which ended June 30, 2019, we spent more than $15 million on contract
labor-primarily on traveling nurses necessary to fill-in for the vacant
In the past three months, we have made good progress to recruit and retain
nurses. Since March 1st, we have hired 130 new registered nurses and added
20 support staff to our float pool (Licensed Vocational Nurses and Certified
Nursing Assistants) to support our registered nurses. We recently made
almost $6 million in salary adjustments for our RNs and started a retention
bonus program for RNs. We continue to work with College of the Sequoias
on its Licensed Vocational Nurses to RN bridge program and we will be
working closely with West Hills College to boost enrollment in its nursing
program. We continue to offer several training programs for new nurses,
which includes a student nurse internship program and a critical care
nurse internship program. We have also hired 65 RN travelers to fill vacancies,
so the number of travelers nearly equates to the number of openings we
have for RNs.
We also have other measures in place to make sure we are always providing
patient care in a safe way. Such efforts include adjusting staffing as
necessary to cover nurse-to-patient ratios with other licensed registered
nurses employed by Kaweah Delta. This includes nurse managers, assistant
managers, team leaders and even clinical educators.
Our Board of Directors, Medical Staff and Executive Team have taken these
findings seriously and filed corrective action plans with the State, which
have been accepted and implemented. We know that our staff is dedicated
and committed to providing our community with the highest quality of patient
care. Each of us at Kaweah Delta is dedicated and committed to providing
our community with the highest quality of patient care. Our goal is always
to do what is best for our patients and to deliver the highest levels
of care for our community.