REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
July 23, 2024
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Emergency Response Department 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 Emergency Response Department 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 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 reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. The ARMC Operations, Policy, and Procedure Manuals reviewed include the following.
The Emergency Response Manual (Manual) contains policies essential to the overall response of ARMC in a disaster related event. The Manual contains the ARMC Basic Emergency Operations Plan, the Department Emergency Operations Plan, and policies and procedures outlining ARMC’s emergency response activities to various threats and incidents ensuring patient and staff safety. The Manual contains a total of 49 policies, of which one has a major revision, 19 have minor revisions, and 29 were reviewed with no changes.
ARMC completed the 2023-2024 review of the Manual and recommends the revisions summarized in Attachment A. Review and update of this Manual is certified in Attachment B.
The one policy with major revisions consists of the following:
• Policy No. 5000.01 v7, Emergency Operations Plan - Addition of attachment and procedural changes.
There are 19 policies that contain minor revisions, which consist of the following:
• Policy No. 5001 v10, Risk Management Notification of Emergency Events - Change Hospital Director to ARMC’s Chief Executive Officer and updated San Bernardino County Communications Center phone number.
• Policy No. 5002 V9, Disaster Planning Activities - Edited for proper verbiage.
• Policy No. 5004 V8, Emergency Communications - Updated location of Ham Radio.
• Policy No. 5004.01 V9, Auxiliary Communications: Ham Radio - Updated location of Ham Radio and Department name.
• Policy No. 5005 V9, Security During Emergency Response - Corrected spelling errors.
• Policy No. 5007 V9, Oxygen System Failure - Corrected grammatical errors.
• Policy No. 5010 V9, Utility Systems and Elevator Failures - Corrected email for duty officer.
• Policy No. 5013 V9, Disaster Organizational Chart - Centered and edited HICS organizational chart.
• Policy No. 5014 V9, Delegation of Responsibilities in Emergencies - Edited for proper verbiage.
• Policy No. 5016 V9, Activation of the Disaster Plan - Corrected grammatical errors.
• Policy No. 5025 V9, Staff Training - Change of title. The Hospital Emergency Preparedness Coordinator to The Hospital Emergency Management Officer.
• Policy No. 5026 V9, Disaster Drills and Evaluation - Removed monitored through the Environment of Care Committee and replaced with details concerning the drill will be controlled by the Emergency Preparedness Committee.
• Policy No. 5027 V9, Shelter-In-Place Plan - Corrected spelling and grammatical errors.
• Policy No. 5029 V9, ARMC Medical Office Building (MOB) Response Plan - Change Hospital Director to ARMC’s Chief Executive Officer
• Policy No. 5030 V9, Bomb Threat - Corrected grammatical errors.
• Policy No. 5032 V9, Active Shooter Response - Added into announcement “Active Shooter”.
• Policy No. 5033 V9, Civil Disturbance Response Plan - Edited for proper verbiage.
• Policy No. 5039 V9, Bioterrorism Chem-Pack Storage and Maintenance - Corrected spelling errors.
• Policy No. 5040 V9, Bioterrorism Response - Edited for grammatical errors.
On July 9, 2024 (Item No. 4), 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, Supervising Deputy County Counsel, 387-5455) on June 25, 2024; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on June 27, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on June 27, 2024; and County Finance and Administration (Paloma Hernandez-Barker, Deputy Executive Officer, 387-5423) on July 3, 2024.