REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
August 8, 2023
FROM
WILLIAM L. GILBERT, Director, 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 Ambulatory Care Primary Care Clinics Policies and Procedures Manual (included and summarized in Attachments A and B).
(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 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, 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 at this time include the following:
Ambulatory Care Primary Care Clinics Policies and Procedures Manual - Review and Certification
The Department of Ambulatory Care Primary Care Clinics Policies and Procedures Manual (Manual) contains policies and procedures regarding quality of patient care within the various Primary Care Clinics. The manual contains a total of 56 policies, of which four policies have major revisions, and 52 policies and the Table of Contents have minor revisions which include grammatical error revisions, the spelling out of abbreviations, as well as changes from using the term “MediTech” to “Electronic Health Record (EHR)”.
ARMC completed the 2019-22 review of this Manual and recommends the revisions summarized in Attachment A. The major revisions to the four policies are as follows:
PCC Policy 322.00 v7 - Late Arrival-No Show Appointments: Includes changes made to workflow adjusting to the adoption of the new electronic health record, and includes process escalation to the chain of command.
PCC Policy 446.00 v4 - Endoscope- Fiber Optiv- Cleaning Procedure- Manual Cleaning: Policy deleted as no longer performed in the Primary Care Clinics.
PCC Policy 518.00 v2 - Prenatal Care: Abbreviations spelled out, includes additions to the process, and replaces Meditech with electronic health record.
PCC Policy 587.00 v4 - Rhogam Administration to Primary Care Clinic Patients: Updates name to Primary Care Clinic, replaces Meditech with electronic health record.
On July 25, 2023 (Item No. 15), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment B.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387- 5455) on May 19, 2023; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on July 14, 2023; Finance (Jenny Yang, Administrative Analyst, 387-4884) on July 19, 2023; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on July 20, 2023.