REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
March 28, 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 Operations, Policy and Procedure Manuals, included and summarized in Attachments A through E:
1. Mother-Baby Department Policies and Procedures Manual
2. Pediatric Department Policies and Procedures Manual
(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 the policies and procedures of the Administrative Operations Manual, 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 and at 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:
Mother-Baby Department Policy and Procedure Manual - Review and Certification
The Mother-Baby Department Policy and Procedure manual contains policies and procedures required by regulation or determined as necessary by ARMC Administration relating to the operations of the Mother-Baby Department. The manual contains 16 policies, including 10 that have minor revisions being recommend for approval. The minor revisions to the 10 policies include clarification of referenced names, grammatical corrections, and locations.
ARMC completed the 2020-2022 review of the policy revisions and recommends the revisions summarized in Attachment A. Review and update of this manual is certified in attachment B.
Pediatric Department Policy and Procedure Manual - Review and Certification
The Pediatric Department Policy and Procedure manual contains policies and procedures required by regulation or determined as necessary by ARMC Administration relating to the operation of the Pediatric Department. The manual contains 12 policies. The one major revision is the deletion of Policy No. 227.00 v.2, as it is already reflected in the general nursing policies. Seven policies in the manual, along with the table of contents, contain minor revisions. The minor revisions to the seven policies include clarification of referenced names, grammatical corrections, removed numerical references, and added references.
ARMC completed the 2020-2022 review of the policy revisions and recommends the revisions summarized in Attachment C. Review and update of this manual is certified in Attachment D.
On February 28, 2023 (Item No. 12), 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, Deputy County Counsel, 387- 5455) on March 24, 2023; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on March 6, 2023; Finance (Jenny Yang, Administrative Analyst, 387-4884) on March 6, 2023; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on March 8, 2023.