REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF THE COUNTY OF SAN BERNARDINO
AND RECORD OF ACTION
June 8, 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 E):
1. Department of Nursing Policy and Procedure Manual
2. Administrative Policy and Procedure Manual
3. Pharmacy Services Policy and Procedures 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 Nursing Policy and Procedure Manual - Policy Revisions
The Department of Nursing Policy and Procedure Manual contains nursing policies and procedures required by regulation or determined by ARMC Administration to pertain to the nursing staff in the delivery of quality services. The ARMC Department of Nursing Manual is necessary to maintain compliance with policy and regulatory bodies. The manual contains a total of 120 policies, of which one has a major revision relating to Urinary Bladder Catheterization. ARMC completed the 2020-21 review of the policies and recommends the revision summarized in Attachment A.
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 two have minor revisions. The first revision includes the use of missing and eloped patient codes. The second addresses intravenous admixtures and administration. ARMC completed the 2020-21 review of the policy revisions and recommends the revisions summarized in Attachment B.
On May 4, 2021 (Item No. 14), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment C.
Pharmacy Services Policy and Procedure Manual - Review and Update
The Department of Pharmacy Services Policy and Procedure Manual contains hospital-wide policies and procedures regarding department organization and function, patient care, and guidelines for the delivery of quality pharmaceutical services. The manual contains a total of 154 policies, of which 2 policies have major revisions. The first revision retires the Emergency Medications for Staff section as this practice ceased. The second retires the Infection Control - IV Additive Service as the contents have been included in the administrative policy section, ADM 690.36. ARMC completed the 2018-2021 review of the policies and recommends the revisions summarized in Attachment D. Review and update of this manual is certified in Attachment E.
PROCUREMENT
Not Applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5465) on June 1, 2021; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on June 1, 2021; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on June 2, 2021; and County Finance and Administration (Matthew Erickson, County Chief Financial Officer, 387-5423) on June 2, 2021.