REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
December 19, 2023
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Medical Staff Continuing Medical Education Program, Policy, and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept, approve, and certify the Arrowhead Regional Medical Center Medical Staff Continuing Medical Education Program, Policy, and Procedure Manual (included and summarized in Attachments A though 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) as there is no financial impact associated with the approval and certification of the Arrowhead Regional Medical Center (ARMC) Medical Staff Continuing Medical Education Program, Policy, and Procedure Manual.
BACKGROUND INFORMATION
The ARMC Medical Staff is governed by the Bylaws of the Medical Staff, Medical Staff Rules and Regulations, Medical Staff Committee Manual, and the Medical Staff Policy and Procedure Manual (Manual). Medical Staff refers to those physicians (Medical Doctors or Doctors of Osteopathy or their equivalent as defined in Section 3.2 of the Medical Staff Bylaws), dentists, oral and maxillofacial surgeons, clinical psychologists, and podiatrists who have been granted membership in the ARMC Medical Staff pursuant to the Bylaws.
The Continuing Medical Education (CME) Policy and Procedure Manual (Manual) contains policies and procedures required by regulation or determined to be necessary or appropriate by the Medical Staff relating to Medical Staff continuing education requirements at ARMC. The policies may be adopted and amended by a majority vote of the Medical Executive Committee (MEC) of the Medical Staff and become effective following approval by the Board of Supervisors, which serves as the Governing Board of ARMC. The CME Manual is separate from ARMC's Policy and Procedure Manual as the Medical Staff are an independent self-governed organization. One purpose of the Medical Staff organization is to provide continuing medical education programs for members of the Medical Staff.
Continuing Medical Education Program Policy and Procedure Manual - Review and Certification
The Medical Staff completed its 2023 review of the CME Manual and recommends approval of the revisions in the CME Manual, as documented in Attachment A. The CME Manual contains eight policies, one with major revisions to conform to new standards as set forth in Attachment B, and seven with minor revisions. The review and update of this CME Manual is certified in Attachment C.
The one policy that has major revision consist of the following:
• Policy No. 7, Policy on AB1195 - Policy and forms updated to be in line with AB241 and updated California Medical Association (CMA) standards.
The seven policies that have minor revisions consist of the following:
• Policy No. 1, Processing Requests for CME Activity Approval - Changes to associated forms only.
• Policy No. 2, Disclosure and Resolution Policy - Policy and forms updated with CME terminology, definitions, and requirements, to be in line with new CMA standards.
• Policy No. 3, Content Validation - Policy updated with ordering and references. Forms updated to match new CMA standards.
• Policy No. 4, Commercial Support Policy and Agreement - Policy and forms updated with new CME terminology.
• Policy No. 5, Payment of Honoraria and Expenses - Deleted references to Institute for Medical Quality (IMQ).
• Policy No. 6, Policy on Regularly Scheduled Conferences/Series and Forms - Policy updated with new terminology, fixed ordering, and removed obsolete associated forms.
• Policy No. 8, Maintenance of Certification (MOC) - Removed board no longer participating.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by the Medical Executive Committee (Kambiz Raoufi, MD, Chairman, 580-6267) on July 27, 2023; County Counsel (Charles Phan, Deputy County Counsel, 387- 5455) on November 21, 2023; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on November 27, 2023; Finance (Jenny Yang, Administrative Analyst, 387-4884) on November 28, 2023; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on November 29, 2023.