REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
April 29, 2025
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Critical Care Policies and Procedures Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policies in the Critical Care Policies and Procedures Manual (included and summarized in Attachments A through C).
(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 Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manuals are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, along with the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all ARMC Operations, Policy, and Procedure 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 and policies 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 policy manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Critical Care Policy and Procedures Manual (Manual) contains policies and procedures regarding department organization and function, and the provision of intensive high-acuity patient care practices. The Manual contains 42 policies, including a new policy that requires approval. Additionally, the index has been revised to include the new policy.
ARMC recommends the revisions to the Manual as summarized in Attachment A. The new policy, Policy No. 818.00 Issue 1, Pain and Anxiety Control of the Burn Patient During Wound Care, is included in Attachment B and is added to include procedures to safely manage pain and anxiety during wound care for burn patients. It details the required assessment, interventions, and documentation to safely care for the burn patient intra-wound care.
On April 8 (Item No. 7, the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment C.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on February 14, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on April 4, 2025; Finance (Jenny Yang, Administrative Analyst, 387-4884) on April 9, 2025; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on April 10, 2025.