REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
August 5, 2025
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Department of Cardiac Services Policy and Procedure Manual
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 Department of Cardiac Services Policy and Procedure Manual, included and summarized in Attachments A through D.
(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 Manual 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, 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 requires 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.
ARMC policy manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Cardiac Services Policy and Procedure Manual contains the Department Daily Operational Plan, along with policies and procedures outlining the hospital’s emergency response activities and incidents ensuring patient and staff safety. The manual contains a total of 66 policies, of which one policy is new, 18 policies have major changes including three updated policies and 15 deleted policies, 17 policies have minor changes excluding the index, and 30 policies have been reviewed with no changes. The index was revised to reflect the removal of deleted policies and the addition of a new policy.
The Cardiac Services Department completed the 2021-2025 review of the Cardiac Services Manual and recommends the revisions summarized in Attachment A. Review and update of this manual is certified in Attachment B.
There is one new policy submitted. The new policy added to the Manual is included in Attachment C, and consists of the following:
• Policy No. 123.00 v1 Cleaning of Trans Esophageal Echocardiogram Probe Cabinet - New policy created for the addition and maintenance of the probe cabinet.
The three policies with major revisions consist of the following:
• Policy No. 117.00 v2 CPACS Data Backup and Disaster Recovery - Removed inaccurate information for companies no longer used and updated grammar and terminology.
• Policy No. 119.00 v2 Organization Chart and Narrative - Added an organizational chart. Updated grammar, terminology and minimized the wording in the narrative.
• Policy No. 304.00 v2 Computerized Tomography Angiogram of the Coronary Arteries - Updated grammar, terminology and updated references for contrast.
There were 15 policies deleted. These policies contained duplicates to other policies.
• Policy No.103.00 v1 Environmental Safety - Deleted; content is included in Environment of Care (EOC) policy 2007 v7, General Hospital Safety and Patient Management.
• Policy No.113.00 v1 Standards of Dress and Appearance - Deleted; content is included in Administrative (ADM) policy 200.06 v9, Standards of Dress and Appearance.
• Policy No.114.00 v1 Fire Safety - Deleted; content is included in Biomedical Engineering (BIO) policy 5001 v7, Fire Safety.
• Policy No.115.00 v1 Emergency Preparedness - Deleted; content is included in Emergency Response Program (ERM) policy 5000 v9, Emergency Preparedness Program.
• Policy No. 121.00 v1 Security Incident Handling - Deleted; content is included in Administrative (ADM) policy 700.06 v5, Security Incident Procedures and Sanctions.
• Policy No. 201.00 v1 Intravenous Lines; Administration of Medications - Deleted; content is included in Department of Nursing (NRS) policy 580.00 v10, Intravenous (IV) Therapy - General Policies.
• Policy No. 205.00 v1 Intravenous (IV) Contrast Administration and Contrast Reactions - Deleted; content is included in Medical Imaging (RAD) policy 590.00 v3, Intravenous (IV) Injection of Contrast.
• Policy No. 207.00 v1 Emergency Medication Box Exchange - Deleted; content is included in Pharmacy (RX) policy 5.32 v3, Transport Boxes.
• Policy No. 303.00 v1 Electrocardiography - Deleted; content is included in Administrative (ADM) policy 670.04 v4, 12-Lead Electrocardiogram (EKG or ECG).
• Policy No. 412.00 v1 Side/Site Verification and Time Out Procedure - Deleted; content is included in Administrative (ADM) policy 670.15 v11, Side/Site Verification and Time Out Procedure.
• Policy No. 422.00 v1 Chest Pain with ST Segment Elevation/Code STEMI- Deleted; content is included in Administrative (ADM) policy 610.52 v1, Code STEMI.
• Policy No. 424.00 v1 Radiation Safety - Deleted; content is included in Biomedical Engineering (BIO) policy 3016 v7, Radiation Safety and Medical Imaging (RAD) policy 400.00 v4, Radiation Safety Regulations.
• Policy No. 425.00 v1 Safe Environment of Care - Deleted; content is included in Operative Services (OPS) policy 217.07 v6, Safe Environment of Care (Patient Safety).
• Policy No. 426.00 v1 Triage of Patients - Deleted; content is included in Administrative (ADM) policy 610.52 v1, Code STEMI.
• Policy No. 431.00 v1 Malignant Hyperthermia - Deleted; content is included in Administrative (ADM) policy 650.00 v5, Malignant Hyperthermia.
The 17 policies with minor revisions were updated to streamline wording and eliminate terms no longer used.
The minor revisions to the index consisted of updates to reflect the removal of deleted policies as well as the addition of a new policy.
On May 20, 2025 (Item No. 17), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manual listed in Attachment D.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on May 15, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on July 11, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on July 16, 2025.