REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
October 8, 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 following Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Attachments A through F:
1. Department of Ambulatory Care Services - Primary Care Clinics Policy and Procedure Manual
2. Medical Imaging Department Policy and Procedure 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 (Manuals) are non-financial in nature.
BACKGROUND INFORMATION
The 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 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 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 Manuals are reviewed, as applicable, by the respective Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. The Department of Ambulatory Care Services - Primary Care Clinics Policy and Procedure Manual (PCC Manual) and Medical Imaging Department Policy and Procedure Manual (Medical Imaging Manual) were reviewed.
The PCC Manual contains 55 policies and procedures regarding quality of patient care within the various primary care clinics. ARMC recommends the addition of a new policy to the PCC Manual as summarized in Attachment A. The new policy added to the PCC Manual is included in Attachment B and consists of the following:
Policy No. 700.00 v1, Standing Orders for Care Gap Requirements - This policy is added to identify patients requiring diagnostic screening and to provide standards and guidelines for ordered tests approved by the medical staff. Standing orders placed for diagnostic studies and tests outlined in the policy do not require practitioner co-signature and may be placed per protocol by the Care Assistant, Medical Assistant, Licensed Vocational Nurse or the Registered Nurse.
The Medical Imaging Manual contains 145 policies and procedures regarding various imaging techniques used to assist in the diagnosis and treatment of medical conditions by providing detailed internal images of the body. ARMC completed the 2024 review of the Medical Imaging Manual and recommends the revisions summarized in Attachment C. Review and update of the Medical Imaging Manual is certified in Attachment D.
The recommended changes include the addition of one new policy, major revisions to nine policies, and minor revisions to 54 policies. The minor revisions consist of minor grammatical corrections and specifications of acronyms. The Index was also revised to reflect the changes made to the Medical Imaging Manual.
Policy No. 642.00 v1, Proper Use of Contrast Media Warmer, included in Attachment E, is added to accommodate new department protocols.
The nine policies with major revisions include:
• Policy No. 121.00 v2, Organizational Chart - Medical Imaging - Updated the organizational chart.
• Policy No. 400.00 v4, Radiation Safety Regulations - Updated the policy per California Department of Health requirements.
• Policy No. 590.00 v3, IV Injection of Contrast - Changed the lab requirements for contrast.
• Policy No. 611.00 v2, Fluoroscan - Deleted. This piece of equipment has been removed from the premises.
• Policy No. 652.00 v3 MRI Caution Stickers - The MRI caution stickers are no longer being utilized on patient charts.
• Policy No. 661.00 v5, Trophon - Updated the policy to reflect current procedures and protocols.
• Policy No. 700.00 v2, Digitizing Outside Films - Deleted. No longer digitize outside films coming from other facilities.
• Policy No. 702.00 v2, Printing Procedures - Deleted. No longer printing.
• Policy No. 803.00 v2, Printer Downtime - Deleted. No longer utilize a printer.
On September 10, 2024 (Item No. 11), the Board accepted and approved the report of review and certification of the Manuals listed in Attachment F.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on October 4, 2024; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on September 16, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on September 20, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on September 23, 2024