REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF THE COUNTY OF SAN BERNARDINO
AND RECORD OF ACTION
August 20, 2019
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title v
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 BB):
1. Infection Control and Employee Health
2. Administrative Operations
3. Rehabilitation Services
4. Human Resources
5. Specialty Care Clinics
6. Primary Care Clinics
7. Emergency Department
8. Sterile Processing Department
9. Medical Imaging Department
10. Environmental Services
(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:
Infection Control and Employee Health Policy and Procedure Manual
The Department of Infection Control and Employee Health Department Policy and Procedure Manual have been recombined to align with the mission and vision of Arrowhead Regional Medical Center. Historically the Infection Control and Employee Health Policies and Procedures have been combined, with the exception of 2017 when manuals were separated. The Infection Control and Employee Health manual contains 63 policies, of which two new policies have been added, three policies have major changes, 51 policies have minor changes, and seven policies have been reviewed with no changes. ARMC completed the 2019 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 new policy added to the manual is included in Attachment C and D, as listed below:
|
Policy Number |
Policy Title |
|
315 |
Shared Toys Pediatric Areas |
|
801 |
Annual Employee Influenza Vaccination |
Administrative Operations Policy and Procedure 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. The Administrative Operations manual contains 364 policies, of which one policy has been added, two policies have a major revision, three policies have minor revisions, with no review or change to the other polices in the Manual. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment E. Review and update of this manual is certified in Attachment F. The new policy added to the manual is included in Attachment G, as listed below:
|
Policy Number |
Policy Title |
|
670.30 |
Ventilator-Associated Events (“VAE”) Prevention Bundle |
Rehabilitation Services Policy and Procedure Manual
The Rehabilitation Services Department Policy and Procedure Manual contains policies and procedures regarding department organization and function, patient care, and guidelines for the delivery of quality services. The Rehabilitation Services Manual contains 42 policies, of which eight policies have major changes, 27 policies have minor changes, and seven policies have been reviewed with no changes. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment H. Review and update of this manual is certified in Attachment I.
Human Resources Policy and Procedure Manual
The Human Resources Manual contains hospital-wide policies and procedures. The Human Resources Manual contains 15 policies reviewed with no changes. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment J. Review and update of this manual is certified in Attachment K.
Specialty Care Clinics Policy and Procedure Manual
The Specialty Care Clinics Policy and Procedure Manual contains policies and procedures regarding quality of patient care within the various Specialty Care Clinics. The Specialty Care Clinics Policy and Procedure Manual contains 94 policies, of which one new policy has been added. ARMC completed the 2019-20 review of the new policy and recommends the revisions summarized in Attachment L. Review and update of this manual is certified in Attachment M. The new policy added to the manual is included in Attachment N, as listed below:
|
Policy Number |
Policy Title |
|
621 |
High Level Disinfection of Endocavity Probes |
Primary Care Clinics Policy and Procedure Manual
The Primary Care Clinics Policy and Procedure Manual contains policies and procedures regarding quality of patient care within the various Primary Care Clinics. The Primary Clinics Policy and Procedure Manual contains 49 policies and procedures, of which one new policy has been added. ARMC completed the 2019-20 review of the new policy and recommends the revisions summarized in Attachment O. Review and update of this manual is certified in Attachment P. The new policy added to the manual is included in Attachment Q, as listed below:
|
Policy Number |
Policy Title |
|
592 |
Administering Influenza and Pneumococcal Vaccine to Adults |
Emergency Department Policy and Procedure Manual
The Emergency Department Policy and Procedure Manual contains hospital-wide policies and procedures regarding quality of patient care within this specialty. The Emergency Department Manual contains 104 policies, of which four new policies have been added, two policies have major changes, 72 policies have minor changes, and 26 policies have been reviewed with no changes. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment R. Review and update of this manual is certified in Attachment S. The new policy added to the manual is included in Attachment T, as listed below:
|
Policy Number |
Policy Title |
|
504.30 |
Screening, Brief Intervention and Referral |
|
506.00 |
Hospital Emergency Response Team (H.E.R.T.) |
|
508.00 |
Orthopedic Guidelines for Trauma Room Fracture Washouts and Long Bone Fracture Stabilization in Polytrauma Patients |
|
509.10 |
Trauma Patients Admitted to a Non-Surgical Service |
Sterile Processing Department Policy and Procedures
The Sterile Processing Policy and Procedure Manual contains hospital-wide policies and procedures regarding quality of patient care within this specialty. The manual contains a total of 70 policies, of which one policy has a minor revision, with no review or change to the other polices in the Manual. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment U. Review and update of this manual is certified in Attachment V.
Medical Imaging Department Policy and Procedures
The Medical Imaging Manual contains policies and procedures regarding department organization and function, and patient care practices. The manual contains a total of 204 policies, of which one policy has a minor revision, with no review or change to the other polices in the Manual. ARMC completed the 2019-20 review of the policy revisions and recommends the revisions summarized in Attachment W. Review and update of this manual is certified in Attachment X.
Environmental Services Department Policy and Procedure Manual
The Environmental Services Manual contains policies and procedures regarding the cleanliness and sanitation of the hospital. The Emergency Department Manual contains 187 policies, of which one new policy has been added, two policies have major changes, 15 policies have minor changes, 26 policies have been deleted, and 143 policies have been reviewed with no changes. ARMC completed the 2019-20 review of this policy and procedure manual and recommends the revisions summarized in Attachment Y. Review and update of this manual is certified in Attachment Z. The new policy added to the manual is included in Attachment AA, as listed below:
|
Policy Number |
Policy Title |
|
2029 |
Office Assistant II |
The Board has previously accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment BB.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Scott Runyan, Deputy County Counsel, 387-5455) on August 6, 2019; Finance (Amanda Trussell, Principal Administrative Analyst, 387-4773) on August 6, 2019; and County Finance and Administration (Katrina Turturro, Deputy Executive Officer, 387-5423) on August 6, 2019.