An Important Message From Our CEO
By Gary Herbst, Chief Executive Officer
Last week I spoke about publicly-released reports that address the quality
of care we provide to patients at Kaweah Delta. I share this information
with you because we are committed to the health and safety of our patients.
We are always working to provide the highest level of patient care because
it is the right thing to do for our community. We track quality in real-time
and have more than 80 quality-improvement committees, comprised of doctors,
nurses, and staff, who continuously study the care we provide on an individual
patient basis to improve the quality of care for all of our patients.
We have recently learned that the local media will be doing a story focused
on quality of care and patient safety at Kaweah Delta based on recent
and past complaints filed with the California Department of Public Health’s
(CDPH) Center for Health Care Quality (CHCQ). CDPH’s complaint process
is not new. Anyone can file a complaint or report an incident against
a healthcare facility or provider that he or she believes is not following
applicable laws or regulations. CDPH frequently visits hospitals throughout
California, including Kaweah Delta, to investigate these complaints, including
those instances where we self-report a condition of non-compliance.
Since 2016, CDPH has found that the majority of complaints about Kaweah
Delta were unsubstantiated or did not violate regulatory requirements.
For example, since 2018, there have been 130 complaints or incidents reported
to CDPH, with only 28 substantiated with deficiencies. Despite the low
number, we take all complaints from our patients, visitors and employees
very seriously and make every attempt to immediately address and resolve
them. When the State substantiates a claim, we quickly develop a plan
to fix the issue and submit it to the State for approval. For example,
a report this year found that we were out of compliance with nurse-to-patient
staffing ratios in our renal unit with nurses sometimes caring for five
patients instead of four. Meeting nurse-to-patient staffing ratios is
a struggle for nearly all hospitals in California who are simultaneously
facing a national nursing shortage while also dealing with significant
increases in patient demand.
Our plan to address and mitigate this staffing challenge is keenly focused
on our efforts to recruit and retain nurses, which includes going above
and beyond to recruit at a local and national level. Additionally, we
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.
Lastly, when the State does find a serious, substantiated complaint, it
can issue penalties or “immediate jeopardies” to hospitals
that caused or were likely to cause, serious injury or death to patients
for failure to comply with licensing requirements. Since 2016, Kaweah
Delta has received only one such finding, which we told you about in November
2018, when a patient physically struck another patient at our Mental Health
Hospital. Additionally, in 2016, we also received an administrative penalty
from the State, which is not the highest penalty (an immediate jeopardy)
but is considered above a minor violation, when we failed to follow our
policies and procedures to identify the correct surgical site for a patient
having a craniotomy. Again, we took these reports seriously, self-reporting
them both to CDPH. To prevent future occurrences, we took steps to make
policy changes, conducted root cause analyses and carried out intensive
trainings to further educate staff and physicians. We filed corrective
action plans with the State, which were accepted, and have been implemented.
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.