REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
June 28, 2022
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Appointments for Medical and Advanced Practice Professional Staff Membership and/or Clinical Privileges at Arrowhead Regional Medical Center
End
RECOMMENDATION(S)
Recommendation
Approve changes with the following Membership and/or Clinical Privilege categories requested in Attachment A, as recommended by the Medical Executive Committee:
1. Applications for Initial Appointment - Medical Staff
2. Applications for Reappointment - Medical Staff
3. Applications for Initial Appointment - Advanced Practice Professional Staff
4. Completion of Focused Professional Practice Evaluation with Advancement - Medical Staff
5. Completion of Focused Professional Practice Evaluation with Advanced Clinical Privileges -Medical Staff
6. Voluntary Relinquishment of Clinical Privileges - Medical Staff
7. Voluntary Resignation of Membership and/or Clinical Privileges - Medical Staff
8. Voluntary Resignation of Membership and/or Clinical Privileges - Advanced Practice Professional Staff
9. Voluntary Withdrawal of Application for Membership and/or Clinical Privileges - Advanced Practice Professional Staff
(Presenter: William L. Gilbert, Director, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
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) as the changes to membership and/or clinical privileges are non-financial in nature.
BACKGROUND INFORMATION
The Medical Executive Committee (MEC) at Arrowhead Regional Medical Center (ARMC) is required to forward a written report and recommendation to the Board of Supervisors (Governing Body) concerning Medical and Advanced Practice Professional Staff membership, which includes the specific medical practice specialty, Department affiliation, privileges to be granted, disciplinary actions, and any special conditions attached to the membership. The recommendations in Attachment A include an array of actions requested of the Board of Supervisors, including initial appointment of doctors to practice at the hospital, reappointments of doctors to practice who fall within two years of their last appointment, as well as voluntary resignations. Unless temporary privileges have been granted by the ARMC Director, these practitioners do not have the authority to treat patients in their specialty until the Governing Body approves these memberships or clinical privileges.
The recommendations in Attachment A are based upon review and evaluation of the practitioners’ application, verification of education and training, peer recommendations, hospital affiliation verifications, verification from the National Practitioner Data Bank, criminal background, licensing documentation, and the affirmative recommendation from the appropriate ARMC Department Chairman, and Credentials Committee. Upon receipt of the recommendation, the Governing Body shall act on the matter. The Governing Body may adopt, reject, or modify a recommendation from the MEC, or refer the recommendation back to the MEC for further consideration. The Governing Body has final authority for granting, renewing, or denying privileges. Privileges cannot exceed two years. Approval by the Governing Body is required to appoint all practitioners for membership and/or clinical privileges who provide patient care services at ARMC, based on the affirmative recommendation of the MEC.
The recommendations included in Attachment A have been reviewed and approved as applicable by the Department Chairman, Committee on Interdisciplinary Practice, Credentials Committee, and MEC.
This approval process is in accordance with the Medical Staff Bylaws, Centers for Medicare and Medicaid Services, California Code of Regulations Title 22, and the standards of The Joint Commission.
Approval of the changes to membership and/or clinical privileges in the categories identified in Attachment A provide for the safety, health, and social service needs of County residents by ensuring appropriate patient care services at ARMC.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by the Medical Executive Committee (Kambiz Raoufi, MD, Chairman, 580-6267) on April 28, 2022; County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on May 31, 2022; ARMC Finance (Chen Wu, Budget and Finance Officer, 580-3165) on June 1, 2022; Finance (Jenny Yang, Administrative Analyst, 387-4884) on June 2, 2022; and County Finance and Administration (Diana Atkeson, Deputy Executive Officer, 387-5423) on June 2, 2022.