REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
September 10, 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 following Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Attachments A through E:
1. Referral Center Policy and Procedures Manual
2. Infection Control and Employee Health 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 ARMC 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 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 respective Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. The Referral Center Policy and Procedure Manual - Review and Certification (Referral Center Manual) and Infection Control and Employee Health Policy and Procedure Manual - Review and Certification (Infection Control Manual) were reviewed.
The Referral Center Manual contains policies and procedures regarding the operations of the Call/Referral Center for appointments and referrals for the continuity of care. The Referral Center Manual contains 16 policies, of which four policies have minor changes and 12 policies have been reviewed with no changes.
ARMC completed the 2022-223 review of the Referral Center Manual and recommends the revisions summarized in Attachment A. Review and update of this manual is certified in Attachment B.
The four policies with minor revisions consist of the following:
• Policy No. 102.00 v2, Plan of Provision of Care - Updated to include new positions added to the department.
• Policy No. 201.00 v2, Referral Center Operation Guidelines - Updated hours of operation.
• Policy No. 301.00 v2, Appointment Scheduling - Updated hours of operation.
• Policy No 310.00 v2, Management of Customer Inquiries - Updated to match Epic procedures.
The Infection Control Manual contains policies and procedures that provide a safe and healthy work environment for every ARMC employee and maintains an effective infection control program that encompasses patients, healthcare workers, visitors, vendors, contractors, services and facilities at ARMC. The Infection Control Manual contains 65 policies, of which five policies have major revisions, with three of these being deleted, four policies and the Index have minor revisions, and 56 policies have been reviewed with no changes.
ARMC completed the 2022-23 review of this policy and procedure manual and recommends the revisions summarized in Attachment C. Review and update of this manual is certified in Attachment D.
The five policies with major revisions consist of the following:
• Policy No. 502.00 v8, Occupational Exposure to Blood or Body Fluids - Was combined with Policy No. 502.01 v9.
• Policy No. 502.01 v9, Post Human Immunodeficiency Virus (HIV) Exposure Protocol - Deleted as the contents were merged with Policy No. 502.00 v8.
• Policy No. 503.00 v2, Guidelines for Health Care Personnel with Confirmed or Exposure to Infectious and Communicable Diseases - Added information from Policy Nos. 506.00 and 507.00. Attachment A in the policy was updated to reflect current CDC guidelines and updates to current infection-specific guidance on the management of exposed or potentially infectious healthcare personnel to the following communicable diseases: Diphtheria, Group A Streptococcus, Meningococcal Disease and Pertussis.
• Policy No. 506.00 v4, Exposure to Communicable Diseases - Deleted and merged with Policy No. 503.00 v2.
• Policy No. 507.00 v3, Outbreak Management of Employees with a Communicable Disease Exposure - Deleted and merged with Policy No. 503.00 v2.
There are four policies that contain minor revisions; these policies consisted of minor updating of formatting and grammar. Minor revisions to the Index included removing deleted policies.
On August 6, 2024 (Item No. 7), 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 August 2, 2024; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on August 16, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on August 19, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on August 21, 2024.