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 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 D):
1. Administrative Policy and Procedure Manual
2. Emergency Response Manual
(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, 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 Policy and Procedure Manual - Review and Update
The Administrative Policy and Procedures 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 Policy and Procedures Manual contains 367 policies, of which two policies have major changes, pertaining to the Homeless Discharge and Patient Rights. ARMC completed the 2020 review of the policy revisions and recommends the revisions summarized in Attachment A.
Emergency Response Manual - Policy Revisions
The Emergency Response Manual contains the Department Emergency Operations Plan, along
with policies and procedures outlining ARMC’s emergency response activities to various threats
and incidents ensuring patient and staff safety. The manual contains a total of 49 policies, of which one policy is new pertaining to Visitation. ARMC completed the 2020 review of the policies and recommends the revisions summarized in Attachment B. New policies are included in Attachment C, as listed below:
|
Policy Number |
Policy Title |
|
5040.02 |
Visitor Limitations Guidance |
The Board has previously accepted and approved the report of review and certification of ARMC
Operations, Policy, and Procedure Manuals listed in Attachment D.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Michael Markel, Principal Assistant County Counsel, 387-5455) on May 8, 2020; ARMC Finance (Chen Wu, Budget and Finance Officer, 909-580-3165) on May 14, 2020; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on May 25, 2020; and County Finance and Administration (Matthew Erickson, County Chief Financial Officer, 387-5423) on May 25, 2020.