REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF THE COUNTY OF SAN BERNARDINO
AND RECORD OF ACTION
August 6, 2019
FROM
WILLIAM L. GILBERT, Director, 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 I):
1. Administrative
2. Patient Accounts
3. Patient Reception
(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 the revisions as well as the addition of new policies, and the report of the review and certification of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manuals are non-financial in nature, and will not result in the use of Discretionary General Funding (Net County Cost).
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with the policies and procedures of the Administrative Operations Manual, County policies, California Code of Regulations Title 22, Chapters 1 and 5, Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC requirements, all ARMC Operations, Policy, and Procedure Manuals are reviewed and revised, as necessary, a minimum of every year or every three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The aforementioned manuals 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, reviews all ARMC policy manuals. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Administrative Operations Manual
The Administrative Operations Manual contains hospital-wide policies and procedures required by regulation or determined by ARMC Administration to pertain to the entire ARMC facility/staff in the delivery of quality services, and is necessary to maintain compliance with policy and regulatory bodies. As revised, this policy and procedure manual is reviewed by ARMC Hospital Director, as necessary, a minimum of every three years. The manual contains a total of three hundred sixty-nine (369) policies, of which six (6) have been deleted, seventy-seven (77) new policies have been added, eleven (11) policies have major revisions, forty-nine (49) policies have minor revisions and two hundred twenty-six (226) polices have been reviewed with no recommended changes. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment A. Review and update of this manual is certified in Attachment B. The seventy-seven (77) new policies are outlined and included in Attachment C.
Department of Patient Accounts Policy and Procedure Manual
The Department of Patient Accounts Policy and Procedure Manual contains policies and procedures regarding department organization and function, customer service, and for the billing of patient accounts. The manual contains a total of twenty-two (22) policies, which include three (3) new policies, (5) policies with major revisions, and fourteen (14) policies with minor revisions. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment D. Review and update of this manual is certified in Attachment E. The three (3) new policies are outlined and included in Attachment F.
Department of Patient Reception Policy and Procedure Manual
The Department of Patient Reception Policy and Procedure Manual contains policies and procedures regarding department organization and function, customer service, and registration. The manual contains a total of forty-nine (49) policies, which include one (1) policy with major revisions; nine (9) policies with minor revisions and thirty-nine (39) polices have been reviewed with no recommended changes. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment G. Review and update of this manual is certified in Attachment H.
The Board has previously accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment I.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Michael Markel, Principal Assistant County Counsel, 387-5455) on July 15, 2019; Finance (Amanda Trussell, Principal Administrative Analyst, 387-4773) on July 19, 2019; and County Finance and Administration (Katrina Turturro, Deputy Executive Officer, 387-5423) on July 19, 2019.