REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
July 23, 2024
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Appointments for Medical Staff and Advanced Practice Professional Staff Membership, Clinical Privileges, and/or Department Chair at Arrowhead Regional Medical Center
End
RECOMMENDATION(S)
Recommendation
Approve changes with the following Membership and/or Clinical Privilege categories, and the appointment of the Department Chair, as requested in Attachment A, and as recommended by the Medical Executive Committee:
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 - Medical Staff
6. Completion of Focused Professional Practice Evaluation for New Clinical Privileges - Medical Staff
7. Completion of Focused Professional Practice Evaluation with Advancement - Advanced Practice Professional Staff
8. Request for Extension of Focused Professional Practice Evaluation - Advanced Practice Professional Staff
9. Voluntary Resignation of Membership and/or Clinical Privileges - Medical Staff
10. Voluntary Resignation of Membership and/or Clinical Privileges - Advanced Practice Professional Staff
11. Voluntary Withdrawal of Application for Membership and/or Clinical Privileges - Medical Staff
12. Appointment of Chair for Department of Family Medicine - Medical Staff
(Presenter: Andrew Goldfrach, ARMC Chief Executive Officer, 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, clinical privileges and/or department chair have no associated financial impact.
BACKGROUND INFORMATION
The Medical Executive Committee at Arrowhead Regional Medical Center (ARMC) is required to forward a written report and recommendation to the Board of Supervisors (Board) concerning Medical and Advanced Practice Professional Staff membership, which includes the specific medical practice specialty, Department affiliation, privileges to be granted, disciplinary actions, and any special conditions attached to the membership. Unless temporary privileges have been granted by the Hospital Chief Executive Officer (CEO), these Practitioners do not have the authority to treat patients in their specialty until the Board approves these memberships or clinical privileges. The medical staff bylaws also require that Department Chairs be appointed by the Hospital CEO and Chief Medical Officer and approved by the Medical Executive Committee (MEC), and the Board.
The recommendations in Attachment A are based upon review and evaluation of the practitioners’ application, verification of education and training, peer recommendations, hospital affiliation verifications, verification from the National Practitioner Data Bank, criminal background, licensing documentation, and the affirmative recommendation from the appropriate Department Chairman and Credentials Committee. Upon receipt of the recommendation, the Board shall act on the matter. The Board may adopt, reject, or modify a recommendation from the MEC, or refer the recommendation back to the MEC for further consideration. The Board has final authority for granting, renewing, or denying privileges. Privileges cannot exceed two years. Approval by the Board is required to appoint all practitioners for membership and/or clinical privileges who provide patient care services at ARMC, based on the affirmative recommendation of the MEC.
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 the appointment of the Chair for the Department of Family Medicine 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 (Hyung-Suk Tommy Lee, MD, Chairman, 580-3360) on June 27, 2024; County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on July 3, 2024; ARMC Finance (Chen Wu, Budget and Finance Officer, 580-3165) on July 3, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on July 3, 2024; and County Finance and Administration (Paloma Hernandez-Barker, Deputy Executive Officer, 387-5423) on July 5, 2024.