REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
May 9, 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 Environmental Services Policies and Procedures Manual (included and summarized in Attachments A through C).
(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 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 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, Medical Executive Committee, Quality Management Committee, and ARMC Administration review all ARMC policy manuals. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Environmental Services Department Policy and Procedure Manual - Review and Certification
The Department of Environmental Services Policy and Procedure Manual (Manual) contains hospital-wide policies and procedures regarding the utilization and safety of equipment throughout the hospital. The Manual contains 161 policies, of which eight have major changes including one for deletion, 71 have minor changes, and 82 policies have been reviewed with no changes. The minor revisions to the 71 policies include grammatical errors and correcting the misuse of verbiage in order to provide a more clear and concise policy.
ARMC completed the 2019-2022 review of this Manual and recommends the revisions summarized in Attachment A. Review and update of this Manual is certified in Attachment B. The major revisions to the eight policies are as follows:
EVS Policy 1003 - Organization Chart
The changes that were made to this policy were additions to the overall number of full-time staff and the supervisory structure within the department which outlines chain of command, shift coverage, and areas of responsibility.
EVS Policy 1004 - Scope of Service
The changes that were made in this policy were verbiage corrections and grammatical revisions that reflect a better sense of understanding regarding the scope of services for the Environmental Services Department. Notable revisions that were made are as follows:
• Primary contact information and extension change.
• Change in productivity measure from adjusted patient days to square footage.
• Variance in staffing, which now changes based on growth of services within ARMC.
EVS Policy 1005 - Work Assignments
The changes that were made in this policy were verbiage corrections and grammatical revisions that reflect a better sense of understanding regarding the day-to-day operations of the environmental services staff. Notable revisions that were made are as follows:
• Change in verbiage of the definition of the policy to reflect proper use of vernacular.
• Addition of subordinate responsibility in the absence of a supervisor.
• Change in verbiage related to the method of communication devices from pager to rover.
EVS Policy 4010 - Formaldehyde Spill Plan
This policy is up for deletion because it is an exact copy of policy 4009 - Handling of radioactive emergencies. The process for any hazardous material spills is also covered in policy 4002 - hazardous materials and waste spills, which makes this policy unnecessarily redundant.
EVS Policy 6006 - Response for Environmental Services and Linen (Department Specific)
The changes that were made in this policy were verbiage corrections and grammatical revisions that reflect a better sense of understanding related to area coverage for campus. Notable revisions that were made are as follows:
• Updated job titles for staff.
• Change in verbiage related to the method of communication devices, from beeper to Spectra Link.
• The addition of several new patient units throughout the ARMC main campus.
EVS Policy 8101 - Bed Control Policy
The changes that were made in this policy were verbiage corrections and grammatical revisions that reflect a better sense of understanding related to the implementation the new electronic health record system and the corresponding changes in day-to-day operations. Notable revisions that were made are as follows:
• The method in which discharges are relayed to the Environmental Services staff.
• The process of how Environmental Services monitors the bed control process.
• The method in which staff communicate their progress as it related to bed control.
EVS Policy 8110 - Terminal Cleaning of Isolation Room (Discharge/Transfer)
The changes that were made in this policy were verbiage corrections and grammatical revisions that reflect a better sense of understanding related to the implementation the new Electronic Health Record (EHR) system, the corresponding changes in day-to-day operations, and updated methodology for the cleaning process per CDC/industry standard. Notable revisions that were made are as follows:
• Changes to the definition of the policy to include the new EHR system and department responsibility.
• Changes to operational process related to the new EHR system.
• Updates to the process in which rooms are cleaned per CDC/Industry standards.
EVS Policy 8111 - Terminal Clean of Occupied Patient Rooms
The changes that were made in this policy were verbiage corrections and grammatical revisions that reflect a better sense of understanding related to the implementation the new EHR system, the corresponding changes in day-to-day operations, and updated methodology for the cleaning process per CDC/industry standard. Notable revisions that were made are as follows:
• Changes to operational process related to the new EHR system.
• The addition of the Acknowledge, Introduce, Duration, Explanation, Thank (AIDET) concept into the operational process.
On March 28, 2023 (Item No. 11), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment C.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387- 5455) on March 29, 2023; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on April 17, 2023; Finance (Jenny Yang, Administrative Analyst, 387-4884) on April 18, 2023; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on April 21, 2023.