San Bernardino header
File #: 1692   
Type: Consent Status: Passed
File created: 2/4/2020 Department: Arrowhead Regional Medical Center
On agenda: 2/11/2020 Final action: 2/11/2020
Subject: v Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals
Attachments: 1. ATT - ARMC - 2-11-20- Att F Neonatal Intensive Care Certification, 2. ATT - ARMC - 2-11-20- Att G Pediatric Manual Summary of Policy Revisions, 3. ATT - ARMC - 2-11-20- Att H Pediatric Certification, 4. ATT - ARMC - 2-11-20- Att I Labor and Delivery Manual Summary of Policy Revisions, 5. ATT - ARMC - 2-11-20- Att J Labor and Delivery Certification, 6. ATT - ARMC - 2-11-20- Att K New Labor and Delivery Policies, 7. ATT - ARMC - 2-11-20- Att M Mother - Baby Certification, 8. ATT- ARMC - 2-11-20 - Att L Mother - Baby Manuals Summary of Policy Revisions, 9. ATT - ARMC - 2-11-20 - Att N ARMC Policy and Procedure Manual Approval List, 10. ATT - ARMC - 2-11-20- Att A Respiratory Care Services Manuals Summary of Policy Revisions, 11. ATT - ARMC - 2-11-20- Att B Maternal Child Manual Summary of Policy Revisions, 12. ATT - ARMC - 2-11-20- Att C Maternal Child Certification, 13. ATT - ARMC - 2-11-20- Att D New Maternal Child Health Policies, 14. ATT - ARMC - 2-11-20- Att E Neonatal Intensive Care Manual Summary of Policy Revisions, 15. Item #16 Executed BAI, 16. Executed Attachment C, 17. Executed Attachment F, 18. Executed Attachment H, 19. Executed Attachment J, 20. Executed Attachment M

REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS

OF THE COUNTY OF SAN BERNARDINO

AND RECORD OF ACTION

 

February 11, 2020

 

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 N.):

1.                     Respiratory Care

2.                     Maternal Child Health

3.                     Neonatal Intensive Care

4.                     Pediatric

5.                     Labor and Delivery

6.                     Mother - Baby

(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:

 

Respiratory Care Services Policy and Procedure Manual - Policy Revisions

The Respiratory Care Policy and Procedure Manual contains policies and procedures required by regulation or determined by ARMC Administration to pertain to the administration and application of Respiratory Care. The Respiratory Care Policy and Procedures Manual contains 103 policies, of which one has major changes. ARMC completed the 2019 review of the policy revision and recommends the revisions summarized in Attachment A.

 

Maternal Child Health Department Policy and Procedure Manual - Review and Update

The Department manual contains policies and procedures required by regulation or determined by ARMC Administration to pertain subject matter. The Department manual contains 56 policies, of which 5 new policies have been added, 3 policies have a major revision, 14 policies have minor revisions, and 34 polices have been reviewed with no recommended changes. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment B. Review and update of this manual is certified in Attachment C. New policies are included in Attachment D, as listed below:

 

Policy Number

Policy Title

5204

Blood Products, Refusal of: Pregnant Women

5205.1

Bassinet Technique, Individual

5208.1

Breastfeeding/Breastmilk Use: Mothers/Neonates with Positive Drug Screens

5268

Surrogate Birth Plan

5272

Topical Anesthetic Cream

 

 

Neonatal Intensive Care Department Policy and Procedure Manual - Review and Update

The Department manual contains policies and procedures required by regulation or determined by ARMC Administration to pertain subject matter. The Department manual contains 47 policies, of which 0 new policies have been added, 4 policies have a major revision, 27 policies have minor revisions, and 16 polices have been reviewed with no recommended changes. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment E. Review and update of this manual is certified in Attachment F.

 

Pediatric Department Policy and Procedure Manual - Review and Update

The Department manual contains policies and procedures required by regulation or determined by ARMC Administration to pertain subject matter. The Department manual contains 12 policies, of which 0 new policies have been added, 1 policies have a major revision, 2 policies have minor revisions, and 9 polices have been reviewed with no recommended changes. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment G. Review and update of this manual is certified in Attachment H.

 

Labor and Delivery Department Policy and Procedure Manual - Review and Update

The Department manual contains policies and procedures required by regulation or determined by ARMC Administration to pertain subject matter. The Department manual contains 52 policies, of which 1 new policies have been added, 2 policies have a major revision, 44 policies have minor revisions, and 5 polices have been reviewed with no recommended changes. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment I. Review and update of this manual is certified in Attachment J. New policies are included in Attachment K, as listed below:

 

Policy Number

Policy Title

248.00

Second Stage of Labor, Nursing Care and Management

 

 

Mother - Baby Department Policy and Procedure Manual - Review and Update

The Department manual contains policies and procedures required by regulation or determined by ARMC Administration to pertain subject matter. The Department manual contains 16 policies, of which 0 new policies have been added, 3 policies have a major revision, 4 policies have minor revisions, and 9 polices have been reviewed with no recommended changes. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment L. Review and update of this manual is certified in Attachment M.

 

The Board has previously accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment N.

 

 

PROCUREMENT

Not applicable.

 

REVIEW BY OTHERS

This item has been reviewed by County Counsel  (Michael Markel, Principal Assistant County Counsel, 387-5455) on January 21, 2020; Finance  (Amanda Trussell, Principal Administrative Analyst, 387-4773) on January 21, 2020; and County Finance and Administration  (Matthew Erickson, County Chief Financial Officer, 387-5423) on January 27, 2020.