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
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 following Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals (included and summarized in Attachments A through K):
1. Information Management Department Policy and Procedure Manual
2. Department of Nursing Policy and Procedure Manual
3. Rehabilitation Services Department Policy and Procedure Manual
4. Ambulatory Services Specialty Care Policy and Procedure Manual
(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, the California Code of Regulations Title 22, Chapters 1 and 5, and 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 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:
Information Management Department Policy and Procedure - Review and Certification
The Information Management Department Policy and Procedure Manual (Information Management Manual) contains policies and procedures regarding the management of computer systems for storage, processing, and transmission of information. The manual contains 81 policies, of which eight have major revision, with six of these being deleted; 34 policies and the Table of Contents have minor revisions, and 39 policies have been reviewed with no changes.
ARMC completed the 2022 review of the policy revisions and recommends the revisions to the Information Management Manual summarized in Attachment A. Review and update of this manual is certified in Attachment B.
The eight policies with major revisions consist of the following:
• Policy No. 210.04 v2, Regulatory and Compliance Agencies and Functions - has been removed as responsibilities have been transferred to the Health Information Management Department.
• Policy No. 300.05 v2, End-User Training and Education Classes -removed as this is no longer in place.
• Policy No. 500.05 v2, Remote Access and Internet - dial up technology no longer in place, changed policy name.
• Policy No. 500.11 v2, Dictionary Changes - removed as this is no longer relevant as Epic replaced Meditech as electronic health record.
• Policy No. 700.00 v1, Clinical Division - removed as this is no longer relevant as Epic replaced Meditech as electronic health record.
• Policy No. 800.01 v1, Computer Sign-On Request - removed Attachment A as requests are electronic and no longer on paper.
• Policy No. 900.00 v1, Health Information Division - removed as this is no longer relevant as Epic replaced Meditech as the electronic health record.
• Policy No. 1000.00 v1, Customer Service and Security Division - removed as this is no longer relevant as Epic replaced Meditech as the electronic health record.
There are 34 policies that contain minor revisions; these policies contain minor grammatical revisions and specifications of acronyms.
Department of Nursing Policies and Procedure Manual - Review and Certification
The Department of Nursing Policy and Procedure Manual (Nursing Manual) contains policies and procedures regarding department organization, function, and establishes standards of nursing practice. The policies, procedures, standards of patient care, and standards of nursing practice are developed by the Nurse Executives, Nursing Unit Mangers, Registered Nurses, and other nursing staff members as appropriate. A full review of the policies for this manual was not done; however, two major revisions are recommended. The two revisions are summarized in Attachment C.
The two policies with major revisions consist of the following:
• Policy No. 564.00 v7, Patient Transfers - In House and Interagency - added Emergency Medical Treatment and Labor Act (EMTALA) policy reference (Attachment D), updated lateral transfer to remove order requirement, removed time restrictions for transfers, and removed forms no longer being used.
• Policy No. 580.30 v2, Ultrasound Guided-Peripheral Intravenous Catheter Insertion - updated training component to allow for additional trainers in the process (Attachment E).
Rehabilitation Services Policy and Procedure Manual - Review and Certification
The Rehabilitation Services Department Policy and Procedure Manual (Rehabilitation Services Manual) contains policies and procedures regarding department organization and function, patient care, and guidelines for the delivery of quality rehabilitation services. The Rehabilitation Services Manual contains 37 policies, of which two policies have major changes, 15 policies have minor changes, and 20 policies have been reviewed with no changes.
ARMC completed the 2022 review of the Rehabilitation Services Manual and recommends the revisions summarized in Attachment F. Review and update of this manual is certified in Attachment G.
The two policies with major revisions consist of the following:
• Policy No. 401 v8, Referral to Rehabilitation Services Department - the process for receiving and processing referrals for inpatient and outpatient changed due to the change in the electronic health record system.
• Policy No. 412 v5, Food and Liquid Consistencies for Dysphagia Patients - changed verbiage to be congruent with Nutrition based on Nutrition implementation of International Dysphagia Diet Standardization Initiative.
The 15 policies with minor revisions consist of the following:
• Policy No.100.00 v5, Departmental Mission - changed mission statement to be congruent with hospital wide mission statement.
• Policy No. 101.00 v7, General Information - updated department hours of operation, changed verbiage for reporting occupational injury or illness, payroll application, and reporting clinical services from written to electronic, and updated the administrative director.
• Policy No. 104.00 v5, Scope of Service - updated items housed in department and removal of wound care as a service for physical therapy.
• Policy No. 105.00 v6, Staffing Plan and Assignments - now includes technical staff as service providers for direct patient care.
• Policy No. 203.00 v6, Leave Time Request - clarified who falls under certain classifications of staff.
• Policy No. 300.00 v6, Environment of Care - reorganization of patient safety procedures.
• Policy No. 403.00 v7, Itemized Billing for Rehabilitation Services - changed billing procedure due to electronic health record implementation.
• Policy No.405.00 v6, Patient Assessment and Plan of Care - changed documentation method from written to electronic.
• Policy No. 406.00 v6, Patient Prioritization - added cardiothoracic patients to prioritization.
• Policy No.408.00 v6, Discharge Planning Protocol - added discharge disposition.
• Policy No. 409.00 v5, Provision of Patient & Family Education - added electronic health record’s education section as area to document education and training needs and goals.
• Policy No.410.00 v5, Termination of Rehabilitation Services - added active discharge orders as a basis to terminate rehabilitation services.
• Policy No.413.00 v4, Interdisciplinary Coordination and Continuum of Care - changed communication from written to electronic health record.
• Policy No.414.00 v4, Information System Downtime Procedures - added electronic health record process for discharging patients from rehab services.
• Policy No.503.00 v4, Treatment Technique Utilization - changed sentence structure for strengthening exercises.
Ambulatory Services Specialty Care Policies and Procedure Manual - Review and Certification
The Ambulatory Care Specialty Care Clinics Policy and Procedure Manual (Specialty Care Manual) contains policies and procedures regarding quality of patient care within the various Specialty Care Clinics. The Specialty Care Manual contains 110 policies, of which four policies and the Table of Contents have major revisions, 12 have been deleted, 13 new policies have been added, and 28 have minor revisions.
ARMC completed the 2022 review of the Specialty Care Manual and recommends the revisions summarized in Attachment H. Review and update of this manual is certified in Attachment I.
The five policies and Table of Contents with major revisions consist of the following:
• Table of Contents, Outpatient Specialty Care Policy and Procedure Manual - added new policies from the retired Wound Care Policy Manual. Deleted policies due to change in practice or combined with existing policies.
• Policy No. 241.00 v7, New Hire Orientation and Competency Assessments - added information about competency assessments.
• Policy No. 406.00 v7, Inspection of Equipment - added SPC 266.00 Special Equipment.
• Policy No. 502.00 v6, Patient Flow - updated with new Epic workflows.
• Policy No. 592.00 v6, Medication Administration: General Guidelines and Safe Practices - added the pharmaceutical sample policy.
There are 12 policies that have been deleted. The following policies were deleted due to the policies being no longer in practice, already in existence in the ARMC Administrative policies and procedures or were combined with another existing policy:
• Policy No. 110.00 v5, Definitive Care - deleted as process exists in Specialty Care (SPC) 506.01
• Policy No. 151.02 v4, Scope of Service Rehabilitation Clinic - deleted as rehab clinic is no longer a service line in the specialty clinics.
• Policy No. 178.01 v1, 2-Way Communication Device Use in the Clinics - deleted as the process is no longer in practice.
• Policy No. 243.00 v6, Annual Clinical Competency Assessment - added to SPC 241.00 New Hire Orientation and Competency Assessments.
• Policy No. 266.00 v6, Special Equipment - combined with SPC 406.00 Inspection of Equipment.
• Policy No. 268.00 v5, Pulse Oximeter - deleted as the process is not practiced by clinic staff. Oximetry is performed by Respiratory Therapists who bring their own equipment.
• Policy No. 343.00 v5, Billing Process / Encounter Forms - the Billing department is to submit a new ARMC policy on the billing process.
• Policy No. 344.00 v6, Provision of Medical Supplies, Durable Medical Equipment (DME), and Assistive Devices - deleted as the process is no longer in practice.
• Policy No. 423.00 v6, Safety Information - combined with SPC 241.00 New Hire Orientation and Competency Assessments.
• Policy No. 552.00 v4, Referrals for Specialty Care - deleted information that describes the workflow of the Call and Referral Center (CRC). CRC workflows already exists in CRC policies.
• Policy No. 554.00 v3, Referral to Rehabilitation Services for Assistive Devices - deleted as the process is no longer in practice.
• Policy No. 598.00 v4, Pharmaceutical Samples - deleted and combined with SPC 592.00 Medication Administration.
There are 13 new policies. The new policies added to the manual are included in Attachment J, and consist of the following:
• Policy No. 152.00 v1, Scope of Service Wound Clinic - policy previously named Plan for Provision of Care. The manual was retired, policy renamed, moved to Specialty Care Policies and Procedures Manual and renumbered to SPC 152.00.
• Policy No. 152.01 v1, Patient Referrals to Wound Clinic - policy previously named Patient Referrals. The manual was retired, policy renamed, moved to Specialty Care Policies and Procedures Manual, and renumbered to SPC 152.01.
• Policy No. 152.02 v1, Wound Clinic Initial Assessment - policy previously named Initial Assessment. The manual retired the policy, was renamed, moved to Specialty Care Policies and Procedures Manual, and renumbered to SPC 152.02.
• Policy No. 152.03 v1, Wound Assessment - policy previously under a retired policy manual. It was moved to the Specialty Care Policies and Procedures Manual and renumbered to SPC 152.03.
• Policy No. 152.04 v1, Topical Treatments for Wound - policy previously under a retired policy manual. It was moved to Specialty Care Policies and Procedures Manual and renumbered to SPC 152.04.
• Policy No. 152.05, v1, Secondary Dressings - moved to Specialty Care Policies and Procedures Manual and renumbered to SPC 152.05.
• Policy No. 152.06, v1, Wet to Dry Dressings - moved to Specialty Care Policies and Procedures Manual and renumbered to SPC 152.06.
• Policy No. 152.07, v1, Advanced Wound Care Procedures - moved to Specialty Care Policies and Procedures Manual and renumbered to SPC 152.07.
• Policy No. 152.08, v1, Principles of Advanced Wound Care - moved to Specialty Care Policies and Procedures Manual and renumbered to SPC 152.08.
• Policy No. 152.09, v1, Wound Photography - policy previously named Photography, under a retired policy manual. The manual was renamed and moved to Specialty Care Policies and Procedures Manual and renumbered to SPC 152.09.
• Policy No. 152.10, v1, Body Mechanics - moved to Specialty Care Policies and Procedures Manual and renumbered to SPC 152.10.
• Policy No. 531.00, v1, Outpatient Cervical Ripening with Transcervical Foley - new procedure in Women’s health clinic requiring new policy.
• Policy No. 547.00, v1, Screening and Managing Patients who Verbalize Mental Distress - outlines process for the specialty clinics.
There are 28 policies that contain minor revisions; these policies consisted of minor grammatical revisions and specifications of acronyms.
On August 8, 2023 (Item No.10), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment K.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on August 24, 2023; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on September 1, 2023; Finance (Jenny Yang, Administrative Analyst, 387-4884) on September 11, 2023; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on September 11, 2023.