REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
April 8, 2025
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 Operations, Policy and Procedure Manuals, included and summarized in Attachments A through E:
1. Human Resources Policy and Procedures Manual
2. Cancer Program Policy and Procedures Manual
(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 are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, and the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, 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 reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Human Resources Policies and Procedure Manual (Human Resources Manual) contains 15 hospital-wide policies and procedures relating to the Human Resources Department (Department) specific mission and goals, and the Department role in serving employees within the organization through customer service, performance improvement and coordinated services. ARMC recommends minor revisions to the 15 policies to update the position title of the Human Resources Officer (HRO) to the Human Resources Business Partner (HRBP), to update the temp employee limit, to add to the Organizational Chart attachments, and new classifications and assignments.
The Department completed the 2022-2023 review of the Human Resources Manual and recommends the revisions summarized in Attachment A. Update of this manual is certified in Attachment B.
The Cancer Program Policy and Procedure Manual (Cancer Program Manual) contains 19 policies and procedures for cancer accreditation, cancer registry, and patient navigators. ARMC recommends minor revisions to all 19 policies and the table of content to reflect current practices and references. The ARMC Cancer Program completed the 2024 review of the manual and recommends the revisions summarized in Attachment C. Update of this manual is certified in Attachment D.
On March 11, 2025 (Item No. 5), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment E.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on February 12, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on March 13, 2025; Finance (Jenny Yang, Administrative Analyst, 387-4884) on March 18, 2025; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on March 18, 2025.