REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF THE COUNTY OF SAN BERNARDINO
AND RECORD OF ACTION
May 4, 2021
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. Department of Education Policy and Procedure Manual
2. 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 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 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:
Department of Education Policy and Procedure Manual - Review and Update
The Department of Education Policy and Procedure Manual contains education policies and procedures required by regulation or determined by ARMC Administration to pertain to the Education Department staff in the delivery of quality services. The ARMC Department of Education Manual is necessary to maintain compliance with policy and regulatory bodies. The manual contains 30 policies and procedures, of which all have undergone review or revision. ARMC completed the 2020-21 review of this policy and procedure manual and recommends the revisions summarized in Attachment A and the update of this manual is certified in Attachment B.
Administrative Policy and Procedure Manual - Policy Revisions
The Administrative Policy and Procedure 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 372 policies, of which one has a major revision. ARMC completed the 2020-21 review of the policy revisions and recommends the revisions summarized in Attachment C.
On March 23, 2021 (Item No. 12), the Board 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 (Charles Phan, Deputy County Counsel, 387-5465) on March 26, 2021; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on April 5, 2021; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on April 14, 2021; and County Finance and Administration (Matthew Erickson, Chief Financial Officer, 387-5423) on April 18, 2021.