REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
June 14, 2022
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 C):
1. Administrative Policy and Procedure Manual
2. Department of Nursing 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 Procedure Manuals and Policies are prepared in compliance with the policies and procedures of the Administrative Operations Manual, County policies, California Code of Regulations Title 22, Chapters 1 and 5, Centers for Medicare and Medicaid Services (the Center), The Joint Commission, and other appropriate regulations and guidelines. Per the Center 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 aforementioned 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 reviews all ARMC policy manuals. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Administrative Policy and Procedure Manual - Review and Update
The Administrative Policy and Procedure Manual contains hospital-wide policies and procedures required by regulation or determined by ARMC Administration to pertain to the entire ARMC facility/staff in the delivery of quality services and is necessary to maintain compliance with policy and regulatory bodies. The Administrative Policy and Procedure Manual contains 371 policies, of which four have major revisions and five have minor revisions. The four major revisions include: Policy 110.29 Issue 10, which revised the qualification requirements for financial assistance; Policy 610.01 Issue 7, which was updated to improve patient care by expediting admissions and improving access to care times and reducing ambulance offload delays; Policy 610.38 Issue 2, which updated the transfer of care and transportation procedures for patients on a legal hold status; and Policy 690.24 Issue 4, which was updated to ensure all homeless patients have a discharge plan, in compliance with Senate Bill 1152.
The five minor revisions include: Policy 110.48 Issue 2, which adds a definition of an implant from the National Uniform Billing Committee; Policy 660.02 Issue 5, which was updated to state that the Laboratory Medical Director or designee shall notify ARMC Risk Management Department via the Event Reporting System; Policy 670.26 Issue 4, which was updated to give registered nurses the ability to administer the pneumococcal and influenza vaccines with a standing order; Policy 670.30 Issue 2, which was updated to evaluate patients for Spontaneous Breathing Trail to facilitate early mobility and tube recommendations for patients expected to require greater than 48 or 72 hours of mechanical ventilation; and Policy 690.27 Issue 5, which changed the House Supervisor notification from Medical Director On-Call to the Department Chair for Family Health Centers and in-house Specialty Clinics. ARMC completed the 2021-2022 review of the policies and recommends the revisions summarized in Attachment A.
Department of Nursing Policy and Procedure Manual - Review and Update
The Department of Nursing Policy and Procedure Manual (Nursing Manual) contains nursing policies and procedures required by regulation or determined by ARMC Administration to pertain to the nursing staff in the delivery of quality services. The ARMC Nursing Manual is necessary to maintain compliance with policy and regulatory bodies. The Nursing Manual contains 123 policies and procedures, of which one related to care of acute stroke patients has major revisions. Specifically, Policy 553.00 was revised to reflect current practice relating to the care of acute stroke patients. ARMC completed the 2022 review of the Nursing Manual and recommends revisions as stated in the 2021-2024 Summary of Policy Revisions in Attachment B.
On May 24, 2022 (Item No. 15), 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 May 11, 2022; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on May 25, 2022; and County Finance and Administration (Diana Atkeson, Deputy Executive Officer, 387-5423) on May 25, 2022.