REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
November 19, 2024
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, 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 Patient Reception Policy and Procedure 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 policies and the report of the review and certification of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manuals (Manuals) are non-financial in nature.
BACKGROUND INFORMATION
The Manuals are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all 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 are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in the 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 Manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. ARMC completed the 2024 review of the Patient Reception Policy and Procedure Manual (Reception Manual) and recommends the revisions summarized in Attachment A. Review and update of the Reception Manual is certified in Attachment B.
The Reception Manual contains 49 policies, which includes 14 policies with major revisions and 23 policies with minor revisions. Additionally, the Table of Contents has minor revisions and 12 polices have been reviewed with no recommended changes.
The fourteen policies with major revisions consist of the following:
• Policy No. 101.00 v9, Plan for Provision of Care - Patient Reception - Change of various department locations; removal of Bed Management / Outpatient Data Entry (OPDE): functions.
• Policy No. 102.00 v1, Management of Information - HIPAA - Deleting due to duplication of Administrative (ADM) policy.
• Policy No. 108.00 v2, Infection Control - Deleting due to duplication of ADM policy.
• Policy No. 112.00 v6, Cashiering Procedure - Change in receipting process and daily deposit process with implementation of new Electronic Health Record (HER).
• Policy No. 117.00 v1, Critical Care Indicators - Deleting due to duplication of ADM policy.
• Policy No. 202.00 v3, Pre-Registration of Emergency Department Patients - Change in processes with implementation of Epic as nursing staff now have the ability to pre-register triage patients.
• Policy No. 208.00 v1, Registration of Aborted Visits - “Left Without Being Seen” and “Elopement” Patients - Deleting - With the implementation of Epic, this function is no longer a Registration Process.
• Policy No. 311.00 v5, Admission & Authorization Procedures - Clinics - Deleting. With the implementation of Epic, this function is no longer a Registration Process.
• Policy No. 317.00 v3, Renal Dialysis Registration - Removed booking and discharge steps as these are no longer Registration processes in Epic.
• Policy No. 317.01 v2, Renal Dialysis Appointment Scheduling - Deleting. With the implementation of Epic, this function is no longer a Registration Process.
• Policy No. 318.00 v2, Registration in the Medical Patient Management Module - Deleting. With the implementation of Epic, this function is no longer a Registration Process.
• Policy No. 401.00 v2, Recurring Visit Registration - Deleting. With the implementation of Epic, this function is no longer necessary.
• Policy No. 500.00 v1, Admission - Discharge - Transfer - Deleting. With the implementation of Epic, this function is no longer a Registration process.
• Policy No. 501.00 v1, Direct Admission from ARMC Clinic / Family Health Center - Deleting. With the implementation of Epic, this function is no longer a Registration process.
The minor revisions to 23 policies relate to grammatical corrections. The Table of Contents was updated to remove the deleted policies.
On October 22, 2024 (Item No.11), the Board accepted and approved the report of review and certification of the 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 October 23, 2024; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on October 25, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on October 31, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on November 1, 2024.