REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
June 25, 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 certification of the Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Schedules A through T:
1. Blood Bank Manual
2. Chemistry Procedure Manual
3. Coagulation Manual
4. Cytology Manual
5. Laboratory General
6. Hematology Manual
7. Histology Manual
8. Information System Manual
9. Microbiology Policies and Procedures Manual
10. Morgue Manual
11. Mycobacterium Manual
12. Mycology Manual
13. Parasitology Manual
14. Pathology Manual
15. Phlebotomy Manual
16. Point of Care Procedure Manual
17. Pre-Analytic Manual
18. Send Out Manual
19. Serology Manual
20. Urinalysis 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:
Clinical Laboratory Operations, Policy and Procedure Manuals - Review and Certification
The Clinical Laboratory Operations, Policy and Procedure Manual (Clinical Lab Manual) contains policies and procedures regarding department organization and function, patient care, various laboratory modalities, and guidelines for the delivery of quality services. The Clinical Lab Manual contains 20 specific manuals, which have a total of 849 policies, of which 27 are new, 68 had major revisions, 117 had minor revisions, and 637 were reviewed without any recommended changes.
ARMC completed the review of these policies in the Clinical Lab Manual and recommends the revisions summarized in Exhibit A. A more detailed summary on the revisions to each of the manuals is set forth on Schedules A through T. The review and update of the Clinical Lab Manual is certified in Attachment A.
The 27 new policies relate to new tests, new methods, new equipment, and new procedures which are included in Attachment B.
The major revisions to the 68 policies include updated references and attachments, deletions of polices, new reagent conversions, updated information, an updated maintenance log, and updated procedures.
The minor revisions to the 116 policies include grammatical corrections, removal of abbreviations, and making technical, procedural and workflow updates.
On June 11, 2024 (Item No. 21), 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, Deputy County Counsel, 387-5455) on June 4, 2024; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on June 4, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on June 6, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on June 7, 2024.