REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
July 9, 2024
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 update/certification of the following Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals, included and summarized in Attachments A through E:
1. Health Sciences Library Policy and Procedure Manual
2. Dialysis Policy and Procedure 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 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, and 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 ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Health Sciences Library Policy and Procedure Manual - Review and Certification
The Health Sciences Library Policy and Procedure Manual (Library Manual) contains policies and procedures required by regulation or determined by ARMC Administration to pertain to management of the library and its resources. The Health Sciences Library has transitioned into a Virtual Library Service. The Library Manual contains 20 policies, of which six policies have major revisions with five policies being deleted, and 14 policies and the Index have minor revisions.
ARMC completed the 2022 review of the policy revisions and recommends the revisions summarized in Attachment A. Review and update of the Library Manual is certified in Attachment B.
The six policies with major revisions consist of the following:
• Policy No. 690.02 v4, Collection Development Policy - Added the content from 690.03 v4.
• Policy No. 690.03 v4, Journal Selection Collection, Acquisition and Maintenance - Deleted; merged with 690.02 v4.
• Policy No. 690.07 v4, Journal Check-in - Deleted as the library has moved to a virtual platform.
• Policy No. 690.08 v2, Weeding and Disposal of Library Materials - Deleted as the library has moved to a virtual platform.
• Policy No. 690.10 v2, Library Facility - Deleted as the library has moved to a virtual platform.
• Policy No. 1000.07 v4, Library Use and Protection of Patient Identifiable Information - Deleted as the library has moved to a virtual platform.
The 14 policies and Index with minor revisions consist of the following:
• The deleted policies were removed from the Index.
• Policy No. 100.01 v5, Mission and Vision - Updated to clarify virtual resources.
• Policy No.100.02 v4, Scope of Service - Updated to clarify virtual resources.
• Policy No. 240.02 v3, Continuing Education - Updated to clarify virtual resources.
• Policy No. 600.03 v2, Copyright, Rights and Responsibilities - Updated to clarify virtual resources.
• Policy No. 602.01 v7, Library Protocols - Updated to clarify virtual resources.
• Policy No. 690.01 v4, Evaluation and Recommendation for Selection of Outside Sources - Updated to clarify virtual resources.
• Policy No. 690.04 v4, Media Services Collection and Development Policy - Updated to clarify virtual resources.
• Policy No. 690.05 v3, Organization - Updated to clarify virtual resources.
• Policy No. 690.06 v6, Interlibrary Loans - Updated to clarify virtual resources.
• Policy No. 690.09 v4, Statistical Information - Updated to clarify virtual resources.
• Policy No. 700.04 v2, Knowledge Based Information Resources and Services - Updated to clarify virtual resources.
• Policy No. 900.00 v2, Networking Affiliations - Updated to clarify virtual resources.
• Policy No. 1072.00 v3, Code Triage: Disaster - Updated to clarify virtual resources.
• Policy No. 1073.00 v2, Emergency Evacuation Plan - Updated to clarify virtual resources.
Dialysis Services Policy and Procedure Manual - Review and Approve Updates
The Dialysis Services Policy and Procedure Manual (Dialysis Manual) contains hospital-wide policies and procedures required by regulation or determined as necessary by ARMC Administration regarding the quality of patient care within this specialty.
As a result of operational changes, the Dialysis Manual is being updated with one new policy and major revisions to 12 existing policies. The Index was also revised to include the new policy and to be consistent with the major revisions to the 12 existing policies. The updates to the Dialysis Manual are summarized in Attachment C.
The new policy added to the Dialysis Manual is included in Attachment D and consists of the following:
• Policy No. 648.00 v1, Hardness Testing - New policy added as a requirement for the new Reverse Osmosis (RO) system installed.
The 12 policies with major revisions consist of the following:
• Policy No. 400.00 v6 Infection Control for Inpatient and Outpatient Dialysis Service - Retired per infection control as there is an existing policy with similar content.
• Policy No. 405.00 v7, Control of Hepatitis B for Inpatient and Outpatient Dialysis Service - Removed bleach concentrate - Will follow manufacturer’s recommendation; grammar correction changing it from “for of disposing” to “for disposing of”.
• Policy No. 410.00 v6, Specified Control Methods (Inpatient and Outpatient Dialysis Service - Removed bleach concentrate, will follow manufacturer’s recommendation.
• Policy No. 413.10 v4, Fresenius Dialysis Delivery System Cleaning and Disinfection - Removed bleach concentrate, will follow manufacturer’s recommendation. Removed specific days of bleach disinfection and changed to manufacturer’s recommendation of weekly; added wording of “dialysis delivery” into system to specify which systems.
• Policy No. 414.00 v6, Cleaning and Disinfection: Patient Treatment Area - removed clamps on items for disinfection as clamps are single use; grammar correction.
• Policy No. 415.00 v4, Bleach Mixing - Removed bleach concentrate, will follow manufacturer’s recommendation.
• Policy No. 604.00 v5, Water Quality Monitoring Log, Stationary Water Treatment System - Removed log attachment.
• Policy No. 619.00 v5, Cleaning/Descaling of Stationary Reverse Osmosis (RO) Membranes - Change descaling frequency to per manufacturer’s guidelines.
• Policy No. 632.10 v4, Chlorine-Chloramine Test of Water with Watercheck 2 - change duration of system flush to per manufacturer’s recommendation due to new Reverse Osmosis (RO) system installation.
• Policy No. 638.00 v5, Cleaning and Disinfection Internal Fluid Pathway of Renal Replacement Therapy Delivery Systems - Removed bleach concentrate, will follow manufacturer’s recommendation.
• Policy No. 640.00 v7, Disinfection of Concentrate Containers and Wands - Removed bleach concentrate, will follow manufacturer’s recommendation.
• Policy No. 641.10 v5, Dialysate Preparation - Acid Mixing Using Granuflo Dissolution Unit II - Removed bleach concentrate, will follow manufacturer’s recommendation.
The minor revisions to the Index consisted of adding one new policy and the removal of one retired policy.
On June 25, 2024 (Item No. 20), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure 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 June 12, 2024; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on June 14, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on June 14, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on June 20, 2024.