REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF THE COUNTY OF SAN BERNARDINO
AND RECORD OF ACTION
October 8, 2019
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title v
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 G.):
1. Sterile Processing
2. Environment of Care
3. Behavior Health
(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 the revisions, 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, and will not result in the use of Discretionary General Funding (Net County Cost).
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals 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 (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC requirements, all ARMC Operations, Policy, and Procedure Manuals are reviewed and revised, as necessary, a minimum of every year or every three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The aforementioned manuals 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:
Sterile Processing Department Policy and Procedure Manual
The Sterile Processing Department Policy and Procedure Manual contains hospital-wide policies and procedures regarding quality of patient care within this specialty. The Sterile Processing Department Manual contains 71 policies, of which 39 have major changes of which 37 were deleted or removed from manual, 29 policies have minor changes, and three policies have been reviewed with no changes. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment A. Review and update of this manual is certified in Attachment B.
Environment of Care Policy and Procedure Manual
The Environment of Care Policy and Procedure Manual contains policies essential to safety of patients, staff and visitors at the hospital. The Environment of Care Manual contains 75 policies, of which one was deleted, 45 policies have minor changes, and 30 policies have been reviewed with no changes. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment C. Review and update of this manual is certified in Attachment D.
Behavior Health Policy and Procedure Manual
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 Behavior Health Manual contains 172 policies, of which 172 have minor changes, 15 policies have been deleted. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment E. Review and update of this manual is certified in Attachment F.
The Board has previously accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment G.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Scott Runyan, Deputy County Counsel, 387-5455) on September 13, 2019; Finance (Amanda Trussell, Principal Administrative Analyst, 387-4773) on September 20, 2019; and County Finance and Administration (Katrina Turturro, Deputy Executive Officer, 387-5423) on September 20, 2019.