REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
March 26, 2024
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Sterile Processing Policy and Procedure Manual
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 Sterile Processing Department Policy and Procedure Manual (included and summarized in Attachments A through 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). Revisions of Policy and Procedure Manuals of the Arrowhead Regional Medical Center (ARMC) Sterile Processing Department are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with County policies, California Code of Regulations Title 22, Chapters 1 and 5, Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and other appropriate regulations and guidelines. Per CMS 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 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.
ARMC policy manuals are review, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and/or ARMC Administration. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Sterile Processing Department Policy and Procedure Manual - Review and Certification
The Sterile Processing Department Policy and Procedure Manual (Manual) contains hospital-wide policies and procedures regarding quality of patient care within this specialty. The Manual contains 33 policies, which include no new policies, two have major revisions, 20 policies have minor revisions, and 11 reviewed with no changes.
ARMC completed the 2019-22 review of the policy revisions and recommends the revisions summarized in Attachment A. The review and update of this manual is certified in Attachment B.
The two policies with major revisions consist of the following:
• Policy No. 600.05 v4, Interdepartmental Function and Relationships - removed Laboratory and Physical Therapy, this is not a current practice.
• Policy No. 1100.55 v3, Biological Monitoring of the Sterrad Sterilizer - removed verbiage under the procedure section regarding specific vendors.
The minor revisions to the 20 policies include grammatical corrections or updated source references.
On March 12, 2023 (Item No. 11), 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 15, 2024; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on March 4, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on March 5, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on March 8, 2024.