REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
February 27, 2024
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Administrative 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 Administrative Policy and Procedure Manuals, included and summarized in Attachments A through C.
(Presenter: William L. Gilbert, Director, 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 Policy and Procedure Manuals of the Arrowhead Regional Medical Center (ARMC) Administrative Department are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with County policies, California Code of Regulations Title 22, Chapters 1 and 5, Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and other appropriate regulations and guidelines. Per CMS and The Joint Commission, 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.
The Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration review all ARMC policy manuals. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Administrative Policy and Procedure Manual - Review and Update
The Administrative Policy and Procedure Manual contains hospital-wide policies and procedures required by regulation or determined by ARMC Administration to pertain to the majority of the ARMC facility and staff in the delivery of quality services. These policies are necessary to maintain compliance with regulatory bodies. The Administrative Policy and Procedure Manual contains a total of 374 policies, of which one policy is new, and the indexes have minor revisions.
ARMC completed the 2023 review of the policy revisions and recommends the revisions to the Administraive Policy and Procedure Manual summarized in Attachment A.
The one new policy added to the manual is included in Attachment B, and consists of the following:
• Policy No. 670.36 v1, Impella Device - The Impella Device is technology that provides short-term circulatory support for critically ill patients and those that have underlying cardiac co-morbidities. The most common use is in cardiac catheterization laboratory during procedures. The device usage has the expected benefit to patients at ARMC by reducing higher level of care transfer to a facility where the device is used, improvement of clinical outcomes for the critically ill that are experiencing circulatory problems and supporting cardiac function during selected procedural care.
The alpha and numeric indexes have minor revisions with the addition of the new policy.
On January 23, 2024 (Item No. 17), 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 (Bonnie Uphold, Supervising Deputy County Counsel, 387- 5455) on January 30, 2024; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on February 2, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on February 7, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on February 9, 2024.