REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
October 22, 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 of the Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Attachments A through I:
1. Operative Services Policy and Procedures Manual
2. Volunteer Services Policy and Procedures Manual
3. Health Information Management Policy and Procedures Manual
4. Administrative Policies and Procedures 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 (Manuals) are non-financial in nature.
BACKGROUND INFORMATION
The 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 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 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 Manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. The Manuals reviewed include the following:
The Operative Services Policy and Procedure Manual (Operative Manual) contains 112 policies and procedures regarding department organization and function and patient care practices. ARMC recommends the addition of, two new policies, minor revisions to the Index, and one policy that has been deleted and is being replaced as summarized in Attachment A.
The two new policies added to the Operative Manual are included in Attachment B, and consist of the following:
• Policy No. 105.12 v1, Operating Room Scheduling - This is a new policy addressing the scheduling process and the use of Operating Rooms (OR). It addresses the scheduling of Elective Case Scheduling, add-ons, and urgent and Emergent cases.
• Policy No. 105.13 v1, Block Scheduling - This is a new policy addressing the allocation of Operation Room Blocks per surgical service line departments or surgeons. The Block Scheduling will be monitored by the Perioperative Executive Committee (PEC) and all changes will be approved by the PEC.
There is one policy that is being removed/replaced.
• Policy No. 105.09 v 7, OR Scheduling Additional Cases - This policy is being replaced by Policy No. 105.12 v1, Operating Room Scheduling. The new policy addresses the OR Scheduling based on current practices and the implementation of the PEC and scheduling cases into the Electronic Health Record.
The Index contains minor revisions addressing the addition of the two new policies and the removal of the one policy being replaced.
The Volunteer Services Policy and Procedure Manual (Volunteer Manual) contains six policies and procedures required by regulation or determined by ARMC Administration that pertain to volunteers. The Volunteer Manual has been reviewed two policies had major revisions, one has minor revisions and three policies and the Table of Contents have been reviewed with no recommended changes.
ARMC completed the 2022 review of the policy revisions and recommends the revisions to the Volunteer Manual summarized in Attachment C. Review and update of the Volunteer Manual is certified in Attachment D.
The two policies with major revisions consist of the following:
• Policy No. 110.01 v3, Volunteer Policy Manual-Dress Standards - Introduction of new uniform, inclusive language in description, and grammatical corrections.
• Policy No. 110.02 v2, Volunteer Policy Manual-Meal Allowance - Corrections made to produce clarity and eliminate repetitiveness in description of policy.
The one policy with minor revisions consists of the following:
• Policy 320.04 v2, Arrowhead Pet Assisted Therapy (APAT) - Minor change of APAT organization due to many changes and additions of certifiable programs.
The Health Information Management Policy and Procedure Manual (Health Information Manual) contains department and hospital-wide policies and procedures governed by various regulations, department organization and function, customer service practices, medical record content and retention, release of information, and coding. The Health Information Manual contains 34 policies, of which one had major revisions, one new policy has been added, seven policies and the Table of Contents had minor revisions, and 25 policies have been reviewed with no changes.
The Health Information Management Department completed the 2022 review and recommends the revisions summarized in Attachment E. Review and update of this manual is certified in Attachment F.
The one policy with major revisions consists of the following:
• Policy No. 371.00 v2, Medical Record Corrections, Late Entries, and Addendums -Updated to be aligned with the new electronic health record (EHR) system (Epic).
The seven policies with minor revisions consist of the following:
• Policy No. 304.00 v3, Master Patient Index - Updating to be aligned with the new EHR system Epic.
• Policy No. 305.00 v2, Duplicate Medical Record Number Reconciliation - Updating to be aligned with the new EHR system Epic.
• Policy No. 321.00 v3, Release of Patient Medical Records/Health Information - Grammatical fixes.
• Policy No. 321.02 v3, Release of Behavioral Health Patient Medical Records/Health Information - Updated the Health Information Management Department phone number. Removed language to workflow. Grammatical fixes.
• Policy No. 328.00 v3, Facsimile Transmissions - Patient Information - Updated policy to reflect Epic processes.
• Policy No. 335.00 v4, Practitioner Suspension and Notification of Incomplete and/or Delinquent Records - Updated policy approved by the Medical Executive Committee, currently in final approval process.
• Policy No. 352.00 v3, Birth Correspondence - Updated policy to reflect the new system being used so that any parent can request a Birth Certificate, updating name from Automated Vital Statistics System to Electronic Birth Registration System.
The Table of Contents was revised to include the new policy.
The new policy added to the Health Information Manual is included in Attachment G and consists of the following:
• Policy No. 102.00 v1, Departmental Organizational Chart - Added Departmental Organizational Chart to illustrate the reporting relationships and chains of command within the organization.
The Administrative (ADM) Policy and Procedure Manual (ADM Manual) contains hospital-wide policies and procedures that are required by regulation or determined by ARMC Administration to pertain to the entire ARMC facility and staff. These instructions are important in the delivery of quality services and are necessary to maintain compliance with policy and regulatory bodies. The Administrative Manual contains 378 policies, of which two have major revisions, 35 have minor revisions, and three were reviewed with no changes.
The ARMC Employee Relations Department recommends the revisions summarized in Attachment H.
The two policies with major revisions consist of:
• Policy No. 200.06 v9, Standards of Dress and Appearance - Updates to clothing, tattoos and jewelry, hair coloring, footwear and accessories. Update CEO to ARMC CEO.
• Policy No. 240.02 v6, Education Assistance Proposal (EAP) Processing for Tuition and Membership Dues - Change CEO to ARMC CEO Remove Education Development’s role; Added Department Supervisor responsibilities; Deleted attachment C; Revised attachment B.
There are 35 policies that contain minor revisions to include updates to references, senior leadership titles, and attachments, as well as including gender-neutral pronouns.
On October 8, 2024 (Item No.13), the Board accepted and approved the report of review and certification of Manuals listed in Attachment I.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on September 20, 2024; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on September 27, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on September 30, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on October 1, 2024.