REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF THE COUNTY OF SAN BERNARDINO
AND RECORD OF ACTION
November 17, 2020
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title v
Arrowhead Regional Medical Center Emergency Response Manual and Infection Control Policies
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 E.):
1. Emergency Response Policy and Procedure Manual
2. Infection Control and Employee Health Policy and Procedure Manual
3. Administrative Policy and Procedure 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 revision to the Emergency Response Manual Policies and the new and revised Infection Control Policies are non-financial in nature, and will not result in the use of Discretionary General Funding (Net County Cost).
BACKGROUND INFORMATION
The ARMC Procedure Manuals and Policies 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 manual and policies 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:
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 has a minor revision. ARMC completed the 2020 review of the policies and recommends the revisions summarized in Attachment A.
Infection Control and Employee Health Policy and Procedure Manual- Policy Revisions
The Infection Control and Employee Health Policy and Procedure Manual has 54 policies related specifically to Infection Control and nine policies related to Employee Health for a total of 63 policies in the Policy and Procedure Manual. No revisions are being made to the Employee Health section of the manual. The Infection Control section has five minor revisions and two new policies. ARMC completed the 2020 review of the policies and recommends the revisions summarized in Attachment B. The two new policies added to the manual are included in Attachment C, as listed below:
|
Policy Number |
Policy Title |
|
328 Issue 1 |
Portable Fans- Cleaning and Use Restrictions |
|
329 Issue 1 |
Ultrasound Gels for Ultrasound- Safe Use |
Administrative Policy and Procedure Manual - Policy Revisions
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 Procedure Manual contains 368 policies, of which one has a major revision. ARMC completed the 2020 review of the policy revisions and recommends the revisions summarized in Attachment D.
September 29, 2020 (Item No. 11), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment E.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on October 8; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on October 9, 2020; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on October 27, 2020; and County Finance and Administration (Matthew Erickson, Chief Financial Executive Officer, 387-5423) on November 01, 2020.