REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
November 3, 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 J:
1. Administrative Policy and Procedure Manual
2. Medical Staff Office Policy and Procedure Manual
3. Medical Staff Office Policy and Procedure Manual for Continuing Medical Education
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 Administrative Policy and Procedure Manual (Admin Manual) contains hospital-wide policies and procedures, which are required by regulation, or determined by the ARMC Administration to pertain to the entire ARMC facility/staff. These policies are important to the delivery of quality services and are necessary to maintain compliance with policy and regulatory bodies. The Admin Manual is comprised of 382 policies, of which two policies are new and two have major revisions. These revisions are needed due to updates to care and to further align with best practices. The table of contents has a minor revision to reflect the addition of the new policies.
ARMC recommends the revisions summarized in Attachment A.
There are two new policies added to the manual, included in Attachments B and C, and consist of the following:
• ADM Policy No. 840.06 Issue 1, Ambient Listening for Clinical Documentation: This policy is for the use of artificial intelligence (AI) ambient listening for clinical documentation. The practitioner documentation system (Microsoft Nuance) has DAX copilot as part of the solution that records audio conversations between the practitioner and patient and patient representative during a visit. This policy governs how ARMC discloses the use of ambient listening, obtains and records patient consent to its use, provides a declination path, and preserves the patient’s right to reach a human at every point. It also provides the use of data, the scope and policy amplification, and monitoring and review of the usage of the solution.
• Policy No. 670.35 v1 Peripheral Intravenous (PIV) Catheter Vasopressor Administration: This new policy establishes standardized requirements for the safe administration of norepinephrine through a peripheral intravenous (PIV) catheter when central venous access is not immediately available or may not be necessary. The policy defines appropriate PIV site selection, medication concentration and dose limits, duration of therapy, nursing monitoring, and management of potential extravasation. The policy supports timely initiation of vasopressor therapy while promoting patient safety and avoiding unnecessary invasive central venous catheter placement in patients requiring short-term vasopressor support.
The two policies with major revisions consist of the following:
• Policy No. 300.03 v18 Organizational Performance Improvement Plan 2026 - Strengthened patient safety governance by defining the Patient Safety Program as a component of the Organizational Performance Improvement Plan and establishing PSQC oversight of the Patient Safety Plan. Clarified patient safety event reporting, review, and analysis requirements. Incorporated review of sociodemographic factors to identify potential disparities. Added a reference to the Adverse Event Policy.
• Policy No. 690.35 v2 Multi-dose and Single-dose Medication Containers - Procedure Section IV.G. regarding beyond use date (BUD) times and references were updated to match pharmaceutical compounding reference (United States Pharmacopeia, USP <797>). Also removed Attachment A, outdated guidance for calculating the 28-day discard date.
The Medical Staff Office Policy and Procedure Manual (MSO Manual) contains policies and procedures required by regulation or determined to be necessary or appropriate by the Medical Staff at ARMC. The MSO Manual contains 21 policies, of which two have major revisions, one has minor revisions, and the table of contents and 18 policies were reviewed with no recommended revisions.
The Medical Staff Office completed the triennial review of the MSO Manual and recommends the revisions summarized in Attachment D. Update of this manual is certified in Attachment E.
The two policies with major revisions consist of the following:
• Policy No. 16 v4-Health Screening and Immunizations - Revised to clarify that physicians only need an annual Tuberculosis (TB) screening if they are working in areas of high risk.
• Policy No. 21 v3-Medical and Advanced Practice Professional Staff Orientation - Revised because orientation is no longer provided in a live setting. Practitioners complete orientation by completing HealthStream modules.
There is one policy that contains minor revisions relating to the proctoring requirements.
The Medical Staff Policy and Procedure Manual for Continuing Medical Education Program (CME Manual) contains policies and procedures required by regulation or determined by the Medical Staff at ARMC relating to continuing medical education for the Medical Staff. The CME Manual contains seven policies, all of which and the table of contents were reviewed with no recommended revisions.
The Medical Staff Continuing Medical Education Program completed its review of the CME Manual with no recommended changes, as reflected in Attachment F. Update of this manual is certified in Attachment G.
The Cancer Program Policy and Procedure Manual (Cancer Manual) contains policies and procedures for cancer accreditation, cancer registry, and patient navigation. The Cancer Manual contains 20 policies, of which one is a new policy that is needed due to updates to care and to further align with best practices. The Index has a minor revision to reflect the addition of the new policy.
The Cancer Program recommends the revisions summarized in Attachment H.
The new policy added to the manual is included in Attachment I, and consists of the following:
• Policy No. 100.09 v1, Smoking Cessation for Patients with Cancer - The Commission on Cancer (CoC) released a new standard in January 2026. All newly diagnosed cancer patients who present to the cancer program for their initial encounter or consultation are to be screened for cigarette smoking. The results will be documented in the Electronic Health Record. Patients who report smoking cigarettes within the past 30 days must be referred for smoking cessation to a treatment facility consistent with Evidence Based Guidelines. Services to be provided onsite or offsite by referral. Referral must be placed within 30 days after the initial encounter and the order will be documented in the electronic health record (EHR) and processed by the Referral Center. Each calendar year the committee will conduct an internal audit on the number of charts specified per the CoC guidelines. The committee must review the complete internal audit results at the end of the calendar year to discuss necessary corrective action plans.
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 J.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on October 8, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on October 9, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on October 9,2026.