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.