San Bernardino header
File #: 11070   
Type: Consent Status: Passed
File created: 10/24/2024 Department: Arrowhead Regional Medical Center
On agenda: 11/5/2024 Final action: 11/5/2024
Subject: Critical Care Policies and Procedures Manual
Attachments: 1. ATT - ARMC - 11-5-24 - Att A - Critical Care Summary of Revisions, 2. ATT - ARMC - 11-5-24 - Att C - ARMC Policy and Procedure Manual Approval List, 3. ATT - ARMC - 11-5-24 - Att B - CC 817.00 v1 Burn Mass Casualty Incident, 4. Item #8 Executed BAI

REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS

OF SAN BERNARDINO COUNTY

AND RECORD OF ACTION

 

                                          November 5, 2024

 

FROM

ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center 

         

SUBJECT                      

Title                     

Critical Care Policies and Procedures Manual

End

 

RECOMMENDATION(S)

Recommendation

Accept and approve the revisions of policies in the Critical Care Policies and Procedures Manual (included and summarized in Attachments A through C).

(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 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.

 

ARMC policy manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. The Critical Care Policies and Procedures Manual (Manual) was reviewed.

 

The Manual contains policies and procedures regarding department organization and function, and provision of intensive high acuity patient care practices. The Manual contains a total of 53 policies, including one new policy and one minor revision to update the index. The Critical Care Department at ARMC recommends the revisions to the Manual as summarized in Attachment A. 

 

 

The new policy added to the Manual is included in Attachment B, and consists of the following:

 

                     Policy No. 817.00 v1. Burn Mass Casualty Incident - This is a new policy created to address the processes for management of patients in which capacity and capability significantly compromises patient care and resources available to treat burn patients, or where the organization is overwhelmed due to prevailing circumstances. This is defined as a disaster event, requiring implementation of this operations plan in the event of a mass casualty.

 

The index contains a minor revision due to the addition of the new policy.

 

On October 22, 2024 (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, Supervising Deputy County Counsel, 387-5455) on September 19, 2024; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on October 10, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on October 15, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on October 18, 2024.