REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
September 26, 2023
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Appointments for Medical Staff and Advanced Practice Professional Staff Membership and/or Clinical Privileges at Arrowhead Regional Medical Center
End
RECOMMENDATION(S)
Recommendation
Approve changes within the following categories to the Arrowhead Regional Medical Center Medical Staff and Clinical Privileges, as recommended by the Medical Executive Committee and documented in Attachment A:
1. Applications for Initial Appointment - Medical Staff
2. Applications for Initial Appointment - Advanced Practice Professional Staff
3. Applications for Reappointment - Medical Staff
4. Applications for Reappointment - Advanced Practice Professional Staff
5. Completion of Focused Professional Practice Evaluation with Advancement - Medical Staff
6. Completion of Focused Professional Practice Evaluation with Advancement - Advanced Practice Professional Staff
7. Request for Extension of Focused Professional Practice Evaluation - Medical Staff
8. Request for Extension of Focused Professional Practice Evaluation - Advanced Practice Professional Staff
9. Request for New Clinical Privileges - Medical Staff
10. Voluntary Resignation of Membership and/or Clinical Privileges - Medical Staff
11. Voluntary Resignation of Membership and/or Clinical Privileges - Advanced Practice Professional Staff
12. Voluntary Withdrawal of Application for Membership and/or Clinical Privileges - Medical Staff
(Presenter: William L. Gilbert, Director, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
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) as the appointments of membership and/or clinical privileges have no associated financial impact.
BACKGROUND INFORMATION
In order for a practitioner to provide medical services at Arrowhead Regional Medical Center (ARMC), the practitioner must become a member of the ARMC Medical Staff or Advanced Practice Professional Staff and be granted privileges in accordance with the requirements of the ARMC Medical Staff Bylaws (Bylaws). To become a member of the Medical Staff or Advanced Practice Professional Staff, a practitioner must meet the qualifications for membership under the Bylaws and apply for initial appointment.
Under the Bylaws, the Medical Executive Committee (MEC) is required to forward a written report and recommendation to the Board of Supervisors (Board) concerning Medical Staff and Advanced Practice Professional Staff membership. If membership is recommended, a written recommendation concerning membership category, Department affiliation, privileges to be granted, and any special conditions to be attached to the membership. As the governing body of the Medical Staff, the Board must review the MEC’s recommendations for appointment and privileges and act on the applications for appointment and privileges. The Board has final authority and discretion to grant or deny membership and privileges, and may adopt, reject, or modify a recommendation from the MEC, or refer the recommendation back to the MEC for further consideration.
The MEC recommends approval of the applications as set forth on Attachment A. The recommendation for approval is based upon the MEC’s review and evaluation of the practitioner’s application, verification of education and training, peer recommendations, hospital affiliation verifications, verification from the National Practitioner Data Bank, criminal background, licensing documentation, and review of all final judgments and settlements of professional liability claims including amounts of payments.
The recommendations included in Attachment A have been reviewed and approved as applicable by the Department Chairman, Committee on Interdisciplinary Practice, Credentials Committee, and MEC.
This approval process is in accordance with the Medical Staff Bylaws, Centers for Medicare and Medicaid Services, California Code of Regulations Title 22, and the standards of The Joint Commission.
Approval of the changes to membership and/or clinical privileges in the categories identified in Attachment A and special conditions associated with appointments in Attachment B will provide for the safety, health, and social service needs of county residents by ensuring appropriate patient care services at ARMC.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by the Medical Executive Committee (Kambiz Raoufi, MD, Chairman, 580-6267) on August 24, 2023; County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on August 22, 2023; ARMC Finance (Chen Wu, Budget and Finance Officer, 580-3165) on September 1, 2023; Finance (Jenny Yang, Administrative Analyst, 387-4884) on September 7, 2023; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on September 11, 2023.