REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
January 23, 2024
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Maternal Child Health 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 Maternal Child Health Department Policy and Procedure Manuals, included and summarized in Attachments A through C.
(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 this item will not result in the use of Discretionary General Funding (Net County Cost). Revisions of Policy and Procedure Manuals of the Arrowhead Regional Medical Center (ARMC) Maternal Child Health Department 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.
The Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration review all ARMC policy manuals. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Maternal Child Health Policy and Procedure Manual - Review and Certification
The Maternal Child Health Policy and Procedure Manual (Manual) contains policies and procedures required by regulation or determined by ARMC Administration that pertains to the specialty. The manual contains 55 policies of which six have major revisions including one that is deleted, 44 policies and the Table of Contents have minor revisions, and five have been reviewed with no changes.
ARMC completed the 2021-2022 review of the policy revisions and recommends the revisions to the Manual as summarized in Attachment A. Review and update of this manual is certified in Attachment B.
The major revisions to the six policies are as follows:
• Policy No. 5201 v3, Baby Friendly Hospital Initiative - Updated to reflect current competency standards and changes in guidelines recommended by Baby Friendly USA and the World Health Organization to maintain ARMC’s baby friendly hospital designation.
• Policy No. 5205 v2, Back to Sleep, Positioning of the Infant - Major changes in wording and grammar but no substantive procedural changes in the practices of sleep positioning for newborns.
• Policy No. 5215 v2, Discharge of a Minor Patient to Someone Other Than the Parent/Legal Guardian - Updates made to the procedure steps to insure social services involvement in care for minors being discharged to non-parent guardians.
• Policy No. 5216 v7, Drug Withdrawal; Neonatal Opioid Exposure - Medication dosage changes made to be consistent with current recommendations and care practice for management of opiate withdrawal in newborns.
• Policy No.5229 v4, Human Immunodeficiency Virus (HIV) Prevention of Prenatal Transmission - Changes in wording, and updates to the procedure throughout the policy to reflect current recommended practice guidelines for management and prevention of transmission of Human Immunodeficiency Virus from mother to infant.
• Policy No. 5258 v1, Pneumocardiogram - Deleted because the practice was obsolete.
There are 44 policies and the Table of Contents that contain minor revisions, consisting of grammatical corrections or updated source references or the removal or reference to any specific electronic documentation system. Policy No. 5258 was removed from the Table of Contents.
On December 19, 2023 (Item No. 16), 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, Deputy County Counsel, 387- 5455) on December 27, 2023; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on December 27, 2023; Finance (Jenny Yang, Administrative Analyst, 387-4884) on December 28, 2023; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on December 28, 2023.