REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
May 24, 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 Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals (included and summarized in Attachments A through I):
1. Emergency Response Policy and Procedure Manual
2. Labor and Delivery Policy and Procedure Manual
3. Infection Control and Employee Health Policy and Procedure Manual
4. Behavioral Health Policy and Procedure Manual
5. Security 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 manual 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:
Emergency Response Policy and Procedure Manual - Review and Update
The Emergency Response Policy and Procedure Manual contains the Department Emergency Operations Plan, along with policies and procedures outlining ARMC’s emergency response activities to various threats and incidents ensuring patient and staff safety. The manual contains a total of 50 policies, of which one policy has a minor revision. Policy 5040.02 v15 Visitor Limitations Policy was revised for visitors who visit for multiple consecutive days in all settings, clarifying that proof of a negative COVID-19 test is only required every third day. ARMC completed the 2022 review of the policies and recommends the revisions summarized in Attachment A.
Labor and Delivery Policy and Procedure Manual - Certification
The Labor and Delivery Policy and Procedure Manual contains policies and procedures required by regulation or determined by ARMC Administration that pertains to the specialty. The manual contains 53 policies, which includes three new policies that have been added, four that have major revisions, including the deletion of one policy, and eleven policies with minor revisions.
The three new policies include: (1) Policy No. 206.00 v1, which was created to assist with caring for observation patients in Labor and Delivery, (2) Policy No. 223.00 v1, which was created to assist with down time procedures, and (3) Policy No. 227.00 v1, which was created for a new piece of equipment utilized in Labor and Delivery.
The four policies that have major revisions are as follows: (1) Policy No. 231.00 v6 pertaining to sterile vaginal speculum examination for obtaining specimens, which was deleted, (2) Policy 203.00 v9, which created a consent form for patients who wish to take their placenta home, (3) Policy No. 242.00 v2, relating to care involving patients with sepsis, which was revised to meet current medical standards, and (4) Policy No. 255.00 v6 pertaining to Methotrexate therapy, which was revised to add additional definitions and to provide further guidance on use of such therapy.
The eleven policies that have minor revisions are as follows: (1) Policy No. 120.04 v10, which changed hours of the Non-Stress Testing clinics and added a resource nurse role, (2) Policy No. 200.00 v9, which added Association of Women’s Health, Obstetrics and Neonatal Nurses guidelines for temperature, (3) Policy No. 202.00 v8, which changed the neonatal resuscitation preparation for high risk deliveries to the Neonatal Intensive Care Unit Charge Nurse will notify Respiratory Therapist for setup, (4) Policy No. 220.00 v9, which updated current guidelines for documentation, (5) Policy No. 232.00 v10, which removed the provision of oxygen before procedure, (6) Policy No. 239.04 v14, which added the Association of Women’s Health, Obstetrics and Neonatal Nurses fetal heart monitoring position statement, (7) Policy No. 240.00 v12, which added a requirement for the reporting of Quantitative Blood Loss to the Practitioner immediately and documentation, (8) Policy No. 241.00 v11, which removed information on placing security protection system, (9) Policy No. 243.00 v8, which updated consent and management of blood products, (10) Policy No. 251.00 v4, which updated information for cleaning and identification of attachment probes, (11) Policy No. 256.00 v6, which added reference to procedures for lap scanning system.
ARMC completed the 2019-2022 review of the policy revisions and recommends the revisions summarized in Attachment B. The review and update of this manual is certified in Attachment C, and the new policies are included in Attachment D, as listed below.
|
Policy Number |
Policy Title |
|
206.00 Issue 1 |
Lap Sponge Scanning Detection System |
|
223.00 Issue 1 |
Downtime Procedure |
|
227.00 Issue 1 |
Limited Observation |
Infection Control and Employee Health Policy and Procedure Manual - Review and Update
The Infection Control and Employee Health Policy and Procedure Manual has 56 policies specifically related to Infection Control and ten policies related to Employee Health, for a total of 66 policies. No revisions are being made to the Employee Health section of the manual. The Infection Control section has one new policy which was created to address the California Department of Public Health recommendation for surveillance due to the recognition of an emerging drug resistant pathogen that colonizes patients with indwelling devices or care associated with Skilled Nursing Facilities or Long Term Acute Care. ARMC has completed the 2021-2022 review of the policies and recommends the revisions summarized in Attachment E. The one new policy added to the manual is included in Attachment F, as listed below:
|
Policy Number |
Policy Title |
|
209 Issue 1 |
Active Surveillance Cultures (ASCs) for Candida Auris. |
Behavioral Health Policy and Procedure Manual - Review and update
The Behavioral Health Policy and Procedure Manual contains policies and procedures regarding department organization and function, customer service and unit specific policies and procedures required by regulation or determined by Behavioral Health Administration and the Behavioral Health Department Leadership team to pertain to the Behavioral Health staff in the delivery of quality patient care services. The manual contains 174 policies, including one that has a major revision. Policy No. 1037 Issue 2, was revised to update the contraband list and to provide more details on the procedures for screening of prohibited items. ARMC completed the 2021-2022 review of this policy and procedure manual and recommends the revisions summarized in Attachment G.
Security Policy and Procedure Manual - Review and update
The Security Policy and Procedure Manual contains policies and procedures regarding the safety of staff and patients. The manual contains a total of 148 policies, including one that has a minor revision. Policy No. 101.671 Issue 3 Code Red: Security Response with the Fire Department was revised to provide guidance regarding contacting the fire department and to update the current National Fire Protection Association Codes. ARMC completed the 2022 review of the policies and recommends the revisions summarized in Attachment H.
On March 15, 2022 (Item No. 9), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment I.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on May 3, 2022; Finance (Chen Wu, Budget and Finance Officer, 387-5285) on May 3, 2022; and County Finance and Administration (Diana Atkeson, Deputy Executive Officer, 387-5423) on May 4, 2022.