REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF THE COUNTY OF SAN BERNARDINO
AND RECORD OF ACTION
June 9, 2020
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title v
Arrowhead Regional Medical Center Medical Staff Bylaws, Rules and Regulations, Committee Manual, and Policies and Procedures
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RECOMMENDATION(S)
Recommendation
1. Accept, approve, and certify the Arrowhead Regional Medical Center Medical Staff Continuing Medical Education Program Policy and Procedure Manual, included and summarized in Attachment A and certified in Attachment G.
2. Approve revisions to the Arrowhead Regional Medical Center Medical Staff Bylaws Article, 6.14.2 Categories of APP Eligible for Advanced Practice Professional Staff which are on file in the office of the Clerk of the Board, as detailed in Attachment B, effective June 9, 2020.
3. Approve revisions to the Arrowhead Regional Medical Center Medical Staff Bylaws Article 10.1 Organization of Departments and Sections, Subsection 10.1.11 Department of Surgery which are on file in the office of the Clerk of the Board as detailed in Attachment C.
4. Accept and approve Arrowhead Regional Medical Center Medical Staff Policy #23 Professional Conduct Attachment D.
5. Approve revisions to the Arrowhead Regional Medical Center Medical Staff Rules and Regulations Section 8 General Rules for Psychiatric Care, which are on file in the office of the Clerk of the Board as detailed in Attachment E.
6. Approve revisions to the Arrowhead Regional Medical Center Medical Staff Committee Manual, which is on file in the office of the Clerk of the Board as detailed in Attachment F.
(Presenter: William L. Gilbert, Director, 580-6150)
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COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of these amendments, revisions, and additions to the Medical Staff Bylaws, Rules and Regulations, Committee Manual, and Policies and Procedures will not result in the use of Discretionary General Funding (Net County Cost) as there is no financial impact associated with the appointments of membership and/or clinical privileges.
BACKGROUND INFORMATION
The Arrowhead Regional Medical Center (ARMC) Medical Staff Bylaws consist of three components: the Bylaws of the Medical Staff, Medical Staff Rules and Regulations, and the Medical Staff Committee Manual. The Medical Staff recommends that the County Board of Supervisors (Board) approve the revisions as documented in Attachment B, Attachment C, Attachment E, and Attachment F to be effective June 9, 2020. Medical Staff Bylaws, Rules and Regulations, and Committee Manuals are reviewed at a minimum of every three years, and all amendments are taken to the Board for approval as they are completed. The Governing Board is responsible for all aspects of the operation of ARMC, including the quality of medical and professional care rendered at the institution. Approval of the revisions to the Medical Staff Bylaws, Rules and Regulations, Committee Manuals, and policies and procedures will provide for the safety, health, and social service needs of County residents by ensuring continued patient care services at ARMC according to the level of care established in these Bylaws.
The Medical Staff Bylaws outline the process by which the Medical Staff review and make recommendations for amendments to the Governing Board. These documents provide for self-governance, the professional and legal structure for Medical Staff operations, organized Medical Staff relations with the Board, and relations with applicants and members of the Medical Staff. The Medical Staff delegated the responsibility to the Medical Staff Bylaws Committee (Bylaws Committee) to periodically review the Medical Staff Bylaws for adherence to laws, regulations, and policies. The Bylaws Committee recommended applicable amendments to the Bylaws of the Medical Staff.
The Medical Staff Executive Committee and the Active Members of the Medical Staff reviewed the recommendations on April 23, 2020, and are proposing amendments to the Medical Staff Bylaws, Rules and Regulations, and Committee Manual as reflected in Attachments B, C, E and F, on file with the Clerk of the Board, for alignment with current healthcare practices, and compliance with the regulations of The Joint Commission (TJC), Centers for Medicare and Medicaid Services Conditions of Participation, Department of Health and Human Services, and California Code of Regulations Title 22.
Accept, approve and certify the Medical Staff Continuing Medical Education Program Policy and Procedure Manual:
• Attachment A - The Medical Staff Continuing Medical Education Program Policy and Procedure manual contains policies and procedures required by regulation or determined by the Medical Staff at ARMC. The Medical Staff CME Manual contains 7 policies, of which 0 policies have been added, 0 policies have major revisions, 0 policies were deleted, and 7 policies have been reviewed with minor changes. The Medical Staff completed the 2020 review of the policy revisions, and recommends the revisions summarized in Attachment A. Review and update of the manual is certified in Attachment G.
Amendments to the Medical Staff Bylaws include the following:
• Attachment B - Article 6.14.2 Categories of APP Eligible for Advanced Practice Professional Staff - Addition of Clinical Perfusion.
• Attachment C - Article 10.1.11 Department of Surgery - Addition of Section of Cardiothoracic Surgery.
Accept and approve Medical Staff Policy #23-Professional Conduct:
• Attachment D - The Medical Staff Policy and Procedure Manual contains policies and procedures required by regulation or determined by the Medical Staff at ARMC. The policy replaces Medical Staff Policy #6-Disruptive Members of the Medical Staff and Advanced Practice Professional Staff, and Medical Staff Policy #7-Code of Conduct, Medical Staff and Advanced Practice Professional Staff.
Amendments to the Medical Staff Rules and Regulations include the following:
• Attachment E - Section 8: General Rules Regarding Psychiatric Care - Deletion of electroconvulsive therapy.
Amendments to the Medical Staff Committee Manual include the following:
• Attachment F - (1) Deletion of the Osteopathic Medical Education Committee (OMEC) -The OMEC was disbanded when the osteopathic residency program was merged with the allopathic residency program; (2) Addition of the Patient Safety Officer and Chief Medical Officer as members of the Peer Review Committee; (3) Addition of the Point of Care Committee, with corresponding descriptions of the committee’s responsibilities, composition, duties, and meeting requirements; and (4) Addition of the Professional Standards Committee, with the corresponding description of responsibilities, composition, duties, and meeting requirements.
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.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by the Medical Executive Committee (Webster Wong, MD, Chairman, 580-3380) on April 23, 2020; County Counsel (Charles Phan, Deputy County Counsel, 387-5455 on May 18, 2020; ARMC Finance (Chen Wu, Budget and Finance Officer, 909-580-3165) on May 20, 2020; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on May 21, 2020; and County Finance and Administration (Matthew Erickson, County Chief Financial Officer, 387-5423) on May 25, 2020.