REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
November 17, 2026
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Medical Imaging Department Policy and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policies of the Arrowhead Regional Medical Center Medical Imaging Department Policy and Procedure Manual, included and summarized in Attachments A and B.
(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 in the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manual are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manual is prepared in compliance with County policies, the California Code of Regulations Title 22, Division 5, Chapter 1, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, 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 manual and policies are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these manuals improves County government operations and provides 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 Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The ARMC Medical Imaging Department Policy and Procedure Manual (Imaging Manual) contains policies and procedures regarding the various imaging techniques, to assist in the diagnosis and treatment of medical conditions by providing detailed internal images of the body. The manual contains 145 policies, of which one policy has major revisions that are needed to further align with best practices.
Medical Imaging Department recommends the revisions summarized in Attachment A.
The one policy with major revisions consists of the following:
• Policy No. 560.00 v3, Critical Findings - Revised to add additional life-threatening findings that require radiologist notification and to provide detailed process for inpatient critical value notification and outpatient critical value.
On October 20, 2026 (Item No. 13), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment B.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on October 16, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on October 21, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on October 22, 2026.