REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
June 23, 2026
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 Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Attachments A through H:
1. Department of Nursing Policy and Procedure Manual
2. Specialty Care Clinic Policy and Procedure Manual
3. Blood Gas Laboratory Policy and Procedure Manual
4. Cancer Program 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 Manual are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are 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 Department of Nursing Policy and Procedures Manual (Nursing Manual) contains policies and procedures regarding department organization and function, and establishes standards of nursing practice. The policies, procedures, standards of patient care, and standards of nursing practice are developed by the Nurse Executives, Nursing Unit Managers, Registered Nurses, and other nursing staff members as appropriate. The Nursing Manual contains 86 policies, of which four policies have major revisions. The revisions are needed to further align with best practices, consolidate policies and update references.
The Department of Nursing recommends the revisions summarized in Attachment A.
The four policies with major revisions consist of the following:
• Policy No. 581.30 v5 Central Vascular Access (Central Line) Management - Subject title updated from “Venous” to Vascular to include all blood vessels instead of just veins. Added language for nurses to assist practitioners with inserting central lines. Neonatal lines to be in their own policy (NRS Policy No. 433.00). “Specialty care Registered Nurse (RN)” updated to be any RN with competency that can perform pressure monitoring, including accessing, maintaining and removing central lines. Removed language for specific nurses to check all lines daily. Inserted procedure steps and details for nurses to assist practitioners for central line insertion including higher risk insertion locations, monitoring and care after insertion and documentation. Removed specific equipment in dressing change kits to indicate use of the kit in general. Removed name brand securement device and made generic term. Removed language for dressing change to be completed after 24 hours and indicated it will be assessed, if needed it will be changed. Added gauze dressing definition and clarified that it will be changed every two days. Changed required documentation from depth of the line to the measurement of the external length. Updated “medical record” to electronic health record (EHR). Fixed grammar. Removed specific procedures for dressing changes and used a reference book for procedure details. Inserted a line to use caution on lines that are not sutured in place. For changes to tubing, solutions and starting new lines, referenced NRS Policy No. 580.00, which is a general intravenous line policy. Added language that the competency is demonstrated by the nurse completing three dressing changes along with annual competency. Added patient assessment and monitoring guidelines. Clarified language on how to assess, flush and change the cap of the line referencing Infection Control Policy No. 325 and included to perform hand washing. Updated the process for removing a specimen from the line. Updated potential problems with central lines, including troubleshooting them. Removed specific instructions for removing a blood clot in the line and referenced manufacturer’s instructions. Changed “physician” to practitioner. Pressure monitoring updated supply list and instructions. Removal of central line instructions updated for best practice. Added that implanted vascular access ports can only be accessed by validated nurses. Peripherally inserted central lines teaching and safety instructions added. Updated patient assessment, monitoring, and home care requirements for the peripherally inserted central lines. References updated. Removed attachment.
• Policy No. 582.00 v9 Peripherally Inserted Central Catheter (PICC) Insertion - Inserted language to reflect the nursing team responsible for placing central catheters. Added general language for the healthcare team to choose appropriate catheter to place. Clarified specific candidate criteria for placement, including those who should not receive catheters. Added line to state that informed consent must be verified. Changed the name of the paper form from Central Line Insertion Practices (CLIP) to the “electronic medical record (EMR)”. Streamlined patient education language and insertion site selections. Catheter insertion supplies now state the kit, verses listing every item. Insertion procedure now states specific techniques in reference verses, stating every step. Removed name brands for ultrasound confirmation. Updated what to document post procedure. Updated possible complications based on references. Removed general safety precautions as those are not specific to this procedure. Removed language for an exchange of catheter, and placed language for preventative strategies to keep line maintained. Competency validation and annual competency updated as to number of lines placed and who observes. Dressing changes referred to policies specific to the line. Updated references.
• Policy No. 583.00 v4 Intravenous (IV) Dressings: Peripheral - Removed central line dressing changes from this policy, leaving it specifically for peripheral. Included language to change dressing whenever integrity impaired. Procedure specifics now reflect in reference. Midline catheter dressings mentioned and referenced to their own policy. Updated references.
• Policy No. 588.00 v3 Midline Catheter - Updated criteria for placing a midline catheter. Policy for administering specific high pH medications through the midline is referenced in ADM Policy No. 690.36. Included language to verify with reference what medications should be administered. Updated precautions. Included to verify order and form for downtime. Changed who can perform dressing change and frequency to all central line and midline policies. Included language for measuring and monitoring arm circumference. Updated language to remove line once no longer indicated. For central lines in the neonatal unit, referenced their policy. Updated references. Removed attachment.
The Specialty Care Clinics Policy and Procedure Manual (Specialty Care Manual) contains policies and procedures regarding quality of patient care within the various Specialty Care Clinics. The Specialty Care Manual contains 100 policies, of which one is new, eight policies have major revisions (including three deletions), 60 policies and the table of contents have minor revisions, and 31 policies were reviewed with no revisions.
The Specialty Care Clinics completed the 2026 review of the Specialty Care Manual and recommends the revisions summarized in Attachment B. Update of this manual is certified in Attachment C.
There is one new policy. The new policy added to the manual is included in Attachment D, and consists of the following:
• Policy No. 575.00 v1. Diabetes Self-Management Education (DSME) Programs - This is a new policy addressing updates to outpatient diabetes education care and the need to further align with DSME program operations with current best practices and national standards.
The five policies with major revisions consist of the following:
• Policy No. 322.00 v7. Appointment Management - Revised to clarify the process.
• Policy No. 400.00 v5. Cleaning of Scope Cabinets - Revised to remove process that is no longer in practice due to switch to disposable scopes.
• Policy No. 402.02 v7. Cleaning Patient Rooms & Equipment - Revised to remove outdated information on enzymatic solution packets.
• Policy No. 585.00 v6. Cystoscopy in Surgery/Urology Clinic - Revised to remove information related to reusable scope. Disposable scopes are now used for this procedure.
• Policy No. 593.00 v7. Rho(D) Immune Globulin (RhIG) Administration - Policy title changed as well as process. Patients must now be established in Women’s Health Clinic in order to receive RhIG. Patients will now be instructed to return within 70 hours after lab draw versus 72 hours.
There are three policies that were deleted. These policies contained outdated position descriptions and processes that are no longer applicable:
• Policy No. 151.03 v2. Scope of Service Cardiac Clinic - Policy deleted due to cardiac services moving to Fontana Family Health Center location. Clinic is no longer part of the ARMC Specialty Care department.
• Policy No. 528.00 v6. Electrocardiogram (EKG) - Policy deleted. Administrative Policies and Procedures ADM Policy No. 670.04 is an administrative EKG policy that applies to all of ARMC.
• Policy No. 591.00 v2. Medication Reconciliation - Policy deleted due to process already existing in ADM Policy No. 610.29.
There are 60 policies and the table of contents that contain minor revisions. These policies contain minor grammatical revisions and specifications of acronyms.
The Blood Gas Laboratory Policy and Procedure Manual (Blood Gas Manual) contains policies and procedures regarding department organization and function, customer service and unit specific policies and procedures required by regulation for delivery of quality patient care services. The Blood Gas Laboratory Manual contains 31 policies and six procedures, of which one policy has a major revision, one policy has a minor revision, and 29 policies, six procedures, and the table of contents were reviewed with no revisions.
The Blood Gas Laboratory completed the 2026 review of the Blood Gas Manual and recommends the revisions summarized in Attachment E. Update of this manual is certified in Attachment F.
The one policy with a major revision consists of the following:
• Policy No. BGL 007 v12 Document Control and Records Retention - Revised to align with the board approved records retention schedule.
There is one policy that contains a minor revision. This policy contains a minor specimen order process change.
The Cancer Program Policy and Procedure Manual (Cancer Program Manual) contains policies and procedures for cancer accreditation, cancer registry, and patient navigation. The cancer accreditation subsection includes eight policies addressing requirements for cancer accreditation through the American College of Surgeons. The cancer registry subsection includes seven policies and procedures of how cancer data is collected and abstracted based on the State of California AB136 law and based in principle on the American College of Surgeons standards. The patient navigation subsection includes four policies and procedures of how patient navigators work to eliminate barriers to care, support patients and family members, and provide necessary education and resources to cancer patients. The Cancer Program Manual contains 19 policies, of which one policy has major revisions that are needed due to updates to care and to further align with best practices.
The Cancer Program recommends the revisions summarized in Attachment G.
The one policy with major revisions consist of the following:
• Policy No. 100.05 v3. Departmental Care Services - The policy was updated to reflect procedure. After our commission on cancer accreditation survey, it was recommended to revise the policy for a better understanding of the distress screening process. Cancer patients are screened for any psychosocial distress related to their cancer diagnosis at least once during their first course of treatment. The screening takes place in the oncology clinic, infusion center, or inpatient unit. The intent of psychosocial services is to improve or resolve psychosocial issues related to cancer care and support resumption of optimal maximum functioning. A qualified social worker collects the data, documents the findings in the patient’s electronic health record (EHR) and makes appropriate referrals for resources and follow up. The annual data report includes the total number of patients screened, number of patients referred for additional psychosocial assessment and support. The report is presented to the oncology committee to identify opportunities for improvement.
On May 5, 2026 (Item No. 11), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment H.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Daniella Hernandez, Deputy County Counsel, 387-5455) on May 20, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on May 29, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on June 2, 2026.