REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
March 15, 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 C) for the 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 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:
Department of Nursing Policy and Procedure Manual - Policy Revisions
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 is new. The new policy is being added to reflect changes in patient care, specifically related to allowing nurses to quickly and efficiently obtain intravenous (I.V.) access in difficult I.V. access points to reduce the number of attempts, increase success rates, and decrease insertion pain. ARMC completed the 2022 review of the Nursing Manual and recommends the addition of the new policy as stated in the 2021-2024 Summary of Policy Revisions in Attachment A. The new policy added to the manual is included in Attachment B, as listed below:
|
Policy Number |
Policy Title |
|
580.30 Issue 1 |
Ultrasound Guided-Peripheral Intravenous Catheter Insertion |
On November 16, 2021 (Item No. 12), 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 February 17, 2022; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on February 18, 2022; and County Finance and Administration (Diana Atkeson, Deputy Executive Officer, 387-5423) on February 23, 2022.