REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
February 11, 2025
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Attachments A through E:
1. Administrative Policy and Procedures Manual
2. Case Management/Utilization Policy and Procedures Manual
3. Environment of Care Policy and Procedures Manual
(Presenter: Andrew Goldfrach, ARMC Chief Executive Officer, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Improve County Government Operations.
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item will not result in the use of Discretionary General Funding (Net County Cost). Revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manuals (Manuals) are non-financial in nature.
BACKGROUND INFORMATION
The Manuals are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all Manuals are reviewed and revised, as necessary, a minimum of every one, two, or three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The Manuals are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these Manuals will improve County government operations and provide for the safety, health, and social service needs of County residents by ensuring policies and procedures are in place for hospital operations and quality patient care.
ARMC Manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. The Manuals reviewed include the Administrative Policy and Procedure Manual (Administrative Manual), Case Management/Utilization Policy and Procedure Manual (Case Management Manual), and Environment of Care Policy and Procedure Manual (Environment of Care Manual).
The Administrative Manual contains 378 policies and procedures, which contain hospital-wide policies and procedures required by regulation or determined by ARMC Administration to pertain to the entire ARMC facility/staff. These instructions are important in the delivery of quality services and are necessary to maintain compliance with policy and regulatory bodies. ARMC recommends major revisions to four policies that are needed due to updates to care and to further align with best practices.
The four policies with major revisions consist of the following:
• Policy No. 220.08 V2, Management of Students and Student Placement - Policy provides guidelines for onboarding and placement of students at ARMC. Changes made to reflect current practice for student placement at ARMC. Orientation for students updated to reflect requirements, policy resources updated for nursing and allied health. Removed duplicate sections.
• Policy No. 610.42 V2, Wound Dressings, Ordering Using Wound Algorithm - Policy provides guidelines for wound treatment and ordering. Updated to appropriate title for Pressure Injury Nurse. Updated to remove Meditech language. Added Wound Care Decision Tree.
• Policy No. 620.09 V7, Screening, Assessment, Reassessment, and Managing Patients at Risk for Suicide - Revised the title of the policy to reflect a seamless process of screening, assessment, reassessment, and managing patients at risk for suicide. Revised to reflect screening of all patients ages 12 or older. Revised to detail the process with varying levels of interventions for corresponding risk levels as well as appropriate interdisciplinary approach to ensure patient safety.
• Policy No. 910.10 V6, Adult End of Life Care (EOLC) - Policy provides guidelines for care for patients at the end of life. Changes made to reflect current evidence-based practice. Additional procedures added for the extubation process with removal of endotracheal tube. Updated goal for relieving suffering. Updated order placement and treatment processes.
ARMC recommends the revisions summarized in Attachment A to the Administrative Manual.
The Case Management Manual contains policies and procedures required by regulation or determined by ARMC Administration. ARMC completed the 2022-24 review of the Case Management Manual and recommends the revisions summarized in Attachment B. The manual contains a total of 57 policies of which 18 have major revisions including 14 deleted policies, 15 policies and the Table of Contents have minor revisions, and 23 policies have been reviewed with no changes.
The 14 deleted policies contained human resources position descriptions which are not required in department policies. Other deleted policies were already covered under other administrative policies.
The four policies with major revisions consist of the following, and have been revised to remove unnecessary processes/documents and to reflect an update to care and alignment with best practices:
• Policy No. 060 Issue 7, Forms/Function - Renamed and combined CM policy 060 and 061. Additional CM 061 not necessary.
• Policy No. 070 Issue 6, Utilization Review Process - Removing conducting retroactive Treatment Authorization Request (TAR) free reviews attachment. No longer applicable.
• Policy No. 082 Issue 3, Coordination Software Discharge Planning Process - Removed previous contracted vendor software name and workflow. Updated to reflect a general name of Coordination Software.
• Policy No. Policy 105 Issue 8, Skilled Nursing Facility Placement - New Pre-Admission Screening and Resident Review process (PASRR) for skilled nursing facility discharges updated in policy.
The minor revisions to 15 policies include updates to how assignments are made, organizational chart phone number updates, abbreviations spelled out per previous recommendations, name change from Health Stream to Learning Management System, and grammatical changes. The Table of Contents was updated to reflect the revisions to the policies.
The review and update of the Case Management Manual is certified in Attachment C.
The Environment of Care Manual contains 76 policies and procedures that are essential for Safety, Security, Hazmat, Medical Equipment, Utilities, Fire and Life Safety that ensure the hospital environment is safe and functional for staff, patients, and visitors. ARMC recommends a major revision to Policy No. 3019 V8, Key and Keypad Code Management, as summarized on Attachment D, to include the keypad coding process and to update the form to reflect the addition of keypad coding.
On January 14, 2025 (Item No. 12), the Board accepted and approved the report of review and certification of the Manuals listed in Attachment E.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on January 14, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on January 17, 2025; Finance (Jenny Yang, Administrative Analyst, 387-4884) on January 21, 2025; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on January 22, 2025.