REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
June 11, 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 or approval of the Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals (included and summarized in Attachments A through R):
1. Security Department Policy and Procedure Manual
2. Operative Services Department Policy and Procedures Manual
3. Labor and Delivery Policy and Procedures Manual
4. Respiratory Care Department Policy and Procedure Manual
5. Blood Gas Lab Policy and Procedure Manual
6. Neurodiagnostic Services Policy and Procedure Manual
7. Hyperbaric Oxygen Therapy Policy and Procedure Manual
8. Pulmonary Function Laboratory Policy and Procedure 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.
The Department Manager, Quality Management Committee, and ARMC Administration review all ARMC policy manuals. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Security Department Policy and Procedure Manual - Review and Certification
The Security Department Policy and Procedure Manual (Security Manual) contains policies and procedures required by regulation or determined by ARMC Administration that pertains to the security of the hospital. The manual contains 147 policies of which 11 have major revisions, the Table of Contents and eight policies have minor revisions, and 128 were reviewed with no changes.
ARMC completed the 2022 review of the policy revisions and recommends the revisions to the Security Manual summarized in Attachment A. Review and update of this manual is certified in Attachment B.
The 11 policies with major revisions consist of the following:
• Policy No. 101.165 v3, Polaris Safety and Operation - Golf Cart and Tram Safety and Operation has been updated as Utility Vehicle Safety and Operation. Procedures were revised to meet the current standards.
• Policy No. 101.201 v3, No Smoking Policy/Enforcement - Updated as verbiage designated smoking areas was removed to meet the current standards of no smoking on campus.
• Policy No. 101.220 v2, Property Handling of 5150 Patients on 72-Hour Hold - Removed section listing patients changing out of their clothing.
• Policy No. 101.421 v3, Interior and Patrols and Responsibilities - Combined with No. 101.431 Exterior Patrols, verbiage has been changed.
• Policy No. 101.431 v1, Exterior Patrols and Responsibilities - Deleted. Combined with Policy No. 101.421.
• Policy No. 101.470 v3, Safety Inspections of Hospital and Grounds - Removed “Tech” from Security Officer responsibilities. Removed coffeepot inspections & stairwell checklists attachment.
• Policy No. 101.679 v3, Code White Pediatric Respiratory/Cardiac Arrest - The policy title changed and the policy was updated to align with the current emergency hospital codes.
• Policy No. 101.730 v1, “If I were a Thief…” Theft Control - Removed attachment flier as attachment is no longer in use.
• Policy No. 101.012 v3, Departmental Specific New Hire Orientation - Removed attachments as department has revised procedures.
• Policy No. 101.013 v3, Security Competency Review - Removed attachments as department has revised procedures.
• Policy No. 101.999 v2, Family Health Center Door and Alarm Codes - Alarm codes were updated.
The eight policies with minor revisions consist of the following:
• Policy No. 101.001 v3, Table of Organization - Revisions made to align with the current organizational chart.
• Policy No. 101.061 v3, Graffiti Reporting, - Minor changes to procedures and responsibilities.
• Policy No. 101.235 v3, Patient Standbys - Minor revisions to law enforcement procedures.
• Policy No. 101.242 v2, Arrowhead Regional Medical Center Patient 5150 Personal Property Handling Procedures - Revisions to the amounts of monies collected and procedures for handling.
• Policy No. 101.295 v2, Release of Bodies to the Coroner or Funeral Homes - Minor changes to verbiage.
• Policy No. 101.420 v3, Use of Wristbands/Visitor Sign-In - Revisions to Wristband Colors/Patterns to align with current wristbands issued to patients, visitors, guests, and vendors.
• Policy No. 101.570 v3, Document Retention - Minor changes to verbiage.
• Policy No. 101.615 v3 Phone Tree Notification - Revisions made to attachments.
The Table of Contents was updated to remove the deleted policy.
Operative Services Policy and Procedure Manual - Review and Certification
The Operative Services Policy and Procedure Manual (Operative Manual) contains policies and procedures regarding department organization and function and patient care practices. The Operative Manual contains a total of 110 policies of which one has major revisions, 11 have minor revisions, and 98 were reviewed with no changes.
ARMC completed the 2022 review of the policies and recommends the revisions and additions summarized in Attachment C and certified in Attachment D.
Policy No. 105.09 v7, Operating Room Scheduling Additional Cases, had a major change from the previous management system, Meditech, to an Electronic Health Record (EHR). This change resulted in application and procedural changes within Meditech to implement ARMC’s new management program EPIC, all revisions are included in this policy.
There are 11 policies that contain minor revisions, such as grammatical error revisions, as well as changes from using the term “Meditech” to “electronic health record” or “EHR”.
Labor and Delivery Policy and Procedure Manual - Review and Approve
The Labor and Delivery Policy and Procedure Manual (L&D Manual) contains policies and procedures required by regulation or determined by ARMC Administration that pertains to the specialty. The L&D Manual has added one new policy and the Table of Contents has a minor revision.
The policy being added is summarized in Attachment E.
The new policy, Policy No. 258.00 v1, Shoulder Dystocia, Management of, was created to identify risk factors and interventions for the management of shoulder dystocia, and is included in Attachment F.
The Table of Contents has a minor revision with the addition of the new policy.
Respiratory Care Services Policy and Procedure Manual - Review and Certification
The Respiratory Care Services Department Policy and Procedure Manual (Respiratory Manual) contains policies and procedures regarding department organization and function, customer service and unit specific policies and procedures required by regulation for delivery of quality patient care services. The Respiratory Manual contains 27 policies and 69 procedures, of which five procedures have major revisions with three of those being retired, 17 policies and 40 procedures and the Index have minor revisions, and the remaining policies and procedures were reviewed with no recommended changes.
ARMC completed the 2022 review of the Respiratory Manual and recommends the revisions summarized in Attachment G. Review and update of this manual is certified in Attachment H.
The five procedures with major revisions consist of the following:
• Procedure No. RCSPC 2 v8, Ventilator Management Protocol - Guidelines - Includes the addition of a table for setting of Positive End Expiratory Pressure related to oxygen requirements.
• Procedure No. RCSPC 16 v5, Preliminary Assessment of Desaturation During Sleep - Retired as the procedure is no longer in use due to outdated and retired technology.
• Procedure No. RCSPC 18 v7, Intermittent Positive Pressure Breathing (IPPB) - Retired as the procedure is no longer in use due to outdated and retired technology.
• Procedure No. RCSPC 22 v9, Demistifier/Nebulization of Specialty Medications - Major changes related to the addition of several medications not previously included resulting in a procedural change in collaboration with the pharmacy and approval by the Pharmacy and Therapeutics Committee.
• Procedure No. RCSPC 28 v8, Small Particle Aerosol Generator (SPAG)/Administration of Ribavirin - Retired as the procedure is no longer in use due to outdated and retired technology.
The minor revisions to the policies and procedures include reference updates, multiple changes to technology, none of which effectively change the therapeutic goal or settings of therapy. The three retired procedures were removed from the Index.
Blood Gas Laboratory Policy and Procedure Manual - Review and Certification
The Blood Gas Laboratory Policy and Procedure Manual (Blood Gas Manual) contains policies and procedures regarding department organization and function, customer service and unit specific policies and procedures required by regulation for delivery of quality patient care services. The Blood Gas Manual contains 32 policies and six procedures, of which one policy is being retired and one procedure has a major revision, 27 policies and five procedures and the Index have minor revisions, and the remaining were reviewed with no recommended changes.
ARMC completed the 2022 review of this policy and procedure manual and recommends the revisions summarized in Attachment I. Review and update of this manual is certified in Attachment J.
Policy No. BGL.021 v12, Proficiency Testing - Personnel is being retired since the media from the manufacturer is no longer available and the requirement is met through other proficiency testing.
Procedure No. BGLPC-4 v8, Edit Deletion of Results, was revised to change the workflow and the ability to undertake certain tasks due to the change in the Electronic Healthcare Record (EHR) system used at ARMC.
There are 32 policies that contain minor revisions related to regulatory references, format changes and technical procedures. References to the term “Meditech” were updated to “Electronic Healthcare Record.” The one policy retired was removed from the Index.
Neurodiagnostic Services Policy and Procedure Manual Review - Review and Certification
The Neurodiagnostic Services Department Policy and Procedure Manual (Neurodiagnostic Manual) contains policies and procedures regarding department organization and function, customer service and unit specific policies and procedures required by regulation for delivery of quality patient care services. The manual contains 18 policies and 30 procedures of which two policies have major revisions as retired, two policies and three procedures and the Index have minor revisions, and the remaining policies and procedures were reviewed with no recommended changes.
ARMC completed the 2022 review of the Neurodiagnostic Manual and recommends the revisions summarized in Attachment K. Review and update of this manual is certified in Attachment L.
The two policies with major revisions consist of the following:
• Policy No. 110 v4, Information Privacy and Security - HIPAA Compliance - Retired since the content is already included in the ARMC Administrative and Environment of Care Policies and Procedures Manuals (EOC Manual).
• Policy No. 113 v4, Safety Policy - Retired since the content is already included in the EOC Manual.
The minor revisions to the two policies and three procedures consisted of the removal of an unnecessary attachment, corrections for grammatical errors, and clarification of who can order continuous electroencephalograms. The two retired policies were removed from the Index.
Hyperbaric Oxygen Therapy Policy and Procedure Manual - Certification
The Hyperbaric Oxygen Therapy (HBOT) Policy and Procedure Manual contains policies and procedures regarding department organization and function, customer service and unit specific policies and procedures required by regulation for delivery of quality patient care services. The HBOT department was previously considered as part of the Ambulatory Services Wound Care Clinic (WCC), but was separated into two ARMC departments. HBOT transferred under Respiratory Care Services leadership, resulting in the request to create a separate policy manual. The HBOT Policy and Procedure Manual is presented as new with ten policies and 15 procedures, which contain only minor revisions.
A summary of the policies in the new manual is included in Attachment M. Certification of the policies and procedures for the manual is in Attachment N.
The ten new policies added to the manual are included in Attachment O, and consist of the following:
• Policy No. 101.00 v1, Staffing Policy - Replaces Ambulatory Services Wound Clinic (WCC) Policy No. 101 v2 Staffing Policy and deletes wound care details.
• Policy No. 102.00 v1, Hyperbaric Oxygen Therapy Team - Replaces WCC Policy No. 102 v2 Wound Care Services Team.
• Policy No. 103.00 v1, Demonstration of Competency - Replaces A WCC Policy No. 103 v2 Demonstration of Competency.
• Policy No. 200.00 v1, Environment of Care - Replaces WCC Policy No. 200 v2 Environment of Care.
• Policy No. 201.00 v1, Infection Control - Replaces WCC Policy No. 201 v2 Infection Control.
• Policy No. 300.00 v1, Ordering Hyperbaric Oxygen - Replaces WCC Policy No. 300 v2 Ordering Hyperbaric Oxygen Therapy.
• Policy No. 301.00 v1, Priority for Hyperbaric Oxygenation Treatments - Replaces WCC Policy No. 301 v2 Priority for Hyperbaric Oxygenation Treatments.
• Policy No. 303.00 v1, Patient Orientation - Replaces WCC Policy No. 303 v2 Patient Orientation.
• Policy No. 305.00 v1, Patient Reassessment - Replaces WCC Policy No. 305 v2 Patient Reassessment.
• Policy No. 308.00 v1, Visitors in Hyperbaric Oxygen Therapy - Replaces WCC Policy No. 308 v3 Visitors in Hyperbaric Oxygen Therapy.
The 15 new procedures added to the manual are included in Attachment O, and consist of the following:
• Procedure No. 200.00 v1, Standard Hyperbaric Oxygen (HBO) Format - Replaces Ambulatory Services Wound Clinic (WCC) 200 v2 Standard Hyperbaric Oxygen (HBO) Format.
• Procedure No. 201.00 v1, Standard Hyperbaric Oxygen (HBO) Procedure - Replaces Ambulatory Services Wound Clinic (WCC) 201 v3 Standard Hyperbaric Oxygen (HBO) Procedure.
• Procedure No. 202.00 v1, Electrocardiogram in Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 202 v2.
• Procedure No. 203.00 v1, Chest Tubes in Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 203 v2
• Procedure No. 204.00 v1, Gastric Tubes in Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 204 v2.
• Procedure No. 205.00 v1, Endotracheal Tubes in Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 205 v2.
• Procedure No. 206.00 v1, Ventilator Support in Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 206 v2.
• Procedure No. 207.00 v1, Intravenous Therapy in Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 207 v2.
• Procedure No. 208.00 v1, Acute Carbon Monoxide Poisoning - Replaces Ambulatory Services Wound Clinic (WCC) 208 v2. Deleted staff personal cell phone numbers from policy.
• Procedure No. 300.00 v1, Emergencies in Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 300 v2.
• Procedure No. 301.00 v1, Equipment Failure in Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 301 v2.
• Procedure No. 302.00 v1, Equipment Care - Replaces Ambulatory Services Wound Clinic (WCC) 302 v2.
• Procedure No. 303.00 v1, Fire Standards for Hyperbaric Oxygen (HBO) - Replaces Ambulatory Services Wound Clinic (WCC) 303 v2.
• Procedure No. 304.00 v1, Performance Verification of Hyperbaric Oxygen (HBO) Chamber - Replaces Ambulatory Services Wound Clinic (WCC) 304 v2.
• Procedure No. 400.00 v1, Body Mechanics - Replaces Ambulatory Services Wound Clinic (WCC) 400 v2.
Pulmonary Function Policy and Procedure Manual - Review and Certification
The Pulmonary Function Laboratory Department Policy and Procedure Manual (Pulmonary Manual) contains policies and procedures regarding department organization and function, customer service and unit specific policies and procedures required by regulation for delivery of quality patient care services. The Pulmonary Manual contains 11 policies and 11 procedures of which one policy had major revisions, eight policies and nine procedures had minor revisions, and the remaining policies and procedures and Index were reviewed with no recommended changes.
ARMC completed the 2022 review of this manual and recommends the revisions summarized in Attachment P. Review and update of this manual is certified in Attachment Q.
Policy No. 11 v2, Downtime Procedures contained major revisions on the downtime procedures related to the replacement of the testing system and the change in workflow in the EHR system.
The minor revisions to the policies and procedures related to reference updates, the removal of an outdated regulatory agency, changing references from “Meditech” to the “Electronic Healthcare Record”, and some device specific technology concerns.
On April 9, 2024 (Item No. 9), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment R.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on May 16, 2024; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on May 16, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on May 21, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on May 22, 2024.