From Our CEO: Transparency & Patient Safety
Transparency & Patient Safety
By Gary Herbst, Chief Executive Officer
At Kaweah Delta, we are always working to provide the highest level of
care to our patients. Our new mission statement reads, “Health is
our passion. Excellence is our focus. Compassion is our promise.”
These words define our purpose in life and why we exist: to care for our
patients and our community. We take this responsibility very seriously.
Our new vision statement is, “To be your world-class healthcare choice,
for life.” A vision statement does not necessarily reflect who an
organization is today, but rather what it aspires to be. That might sound
like an overly-ambitious goal, but we are ranked in the top 5% of all
U.S. hospitals and we are committed to being even better. That requires
dedication to continuous improvement. We also believe that we must be
open and transparent with those that we serve.
The California Department of Public of Health (CDPH) monitors complaints
made against hospitals and incidents that hospitals self-report. As recently
reported by the local media, Kaweah Delta has had a number of complaints
filed against us. We take all complaints from our patients, visitors,
and employees seriously and make every attempt to address and resolve
them. According to CDPH investigations, a majority of the complaints made
against Kaweah Delta during 2019 were unsubstantiated. Despite this, we
still investigate all complaints and look for ways to improve.
This year, there have been 16 substantiated complaints against Kaweah Delta.
We regret all of these incidents and we work hard every day to avoid mistakes.
For each of these cases, we conduct a thorough investigation and provide
CDPH with a plan of correction. While we strive for zero patient complaints,
the reality is that we treat thousands of patients every month. Compared
to other hospitals in CDPH’s Bakersfield region (which monitors
Kaweah Delta), the number of substantiated complaints against Kaweah Delta
is comparable or lower than similar sized hospitals. CDPH also tracks
and reports incidents that hospitals self-report. Kaweah Delta will always
report all incidents to CDPH.
In the spirit of transparency, we want to let you know about two recent
self-reported incidents. While CDPH makes some of this information publicly
available on its website, our commitment is to let you know about these
matters as soon as we have been notified about them, often before they
are posted online.
The first case occurred in April, when we unintentionally left a foreign
object in a patient during a procedure to remove their infected pacemaker.
The patient was not harmed by this event, which we self-reported to CDPH.
The patient’s infection made it particularly hard for our team to
see that a small piece of the pacemaker remained inside the patient. Additionally,
while we performed an X-ray of the patient’s chest before closing,
drainage from the infection made it difficult for the team to see the
remaining piece. As a result, we have improved our policy and now take
a second time-out before closing up a wound in which everyone in that
operating room must agree that nothing remains in the wound before it
is closed. In the past five years, we have performed 1,899 cardiac device-related
procedures similar to this case and 16,471 additional cardiac cases. This
was the first time that a foreign body was retained in a patient’s
body during one of these types of procedures. We are in the process of
writing our plan of correction, which will include re-education of employees
and monthly auditing to make sure we are always following our policies
and procedures and that this mistake does not happen again.
The second incident is related to the improper use of protective bed restraints.
At Kaweah Delta, like other hospitals, we have a policy in place that
allows us to use restraints to control a patient’s physical activity
when they are determined to pose a danger to themselves or others. However,
in July, a physician ordered the use of a soft- limb arm and leg restraint
for a patient in our Medical Center. To prevent self-harm to the patient,
an employee used a non-approved restraint after she deemed the physician-ordered
restraint ineffective. Additionally, a different employee, who was supposed
to monitor the restraint to ensure safe, proper placement, and correct
restraint material, did not do so. Restraints are rarely used at Kaweah
Delta and as a result, we take their use very seriously. This was a clear
breach of our protocol and practice for their use. Both employees are
no longer employed by Kaweah Delta. Important to note, the State did not
find that we were out of nurse-to-patient staffing ratios for this unit
during the incident. Since this event, we have re-educated staff on this
unit on the various types of approved restraints and on proper monitoring
and assessment according to policy. We also perform monthly audits to
ensure we are keeping patients safe.
Unfortunately, medical errors happen at every hospital across the nation.
This is not an excuse. Kaweah Delta is an organization committed to the
health and safety of our community, and it is our responsibility to make
sure that we learn from our mistakes. We own each and every one of those.
We are working to make sure that we are open and honest with our community
about the quality of care that we provide and the efforts we are making