REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
July 13, 2021
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
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 I):
1. Ambulatory Services Cancer Program Policy and Procedure Manual
2. Administrative Policy and Procedure Manual
3. Medical Imaging Policy and Procedure Manual
4. Emergency Response 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, at 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:
Ambulatory Services - Cancer Program Policy and Procedure Manual - New Policies
The Ambulatory Services - Cancer Program Policy and Procedure Manual contains the policies and procedures for cancer accreditation, cancer registry, and patient navigation. The cancer accreditation subsection includes eight policies addressing requirements for cancer accreditation through the American College of Surgeons. The cancer registry subsection includes seven policies and procedures of how cancer data is collected and abstracted based on the State of California AB136 law and based in principle on the American College of Surgeons standards. The patient navigation subsection includes four policies and procedures of how patient navigators work to eliminate barriers to care, support patients and family members, and provide necessary education and resources to cancer patients.
The Ambulatory Services - Cancer Program Policy and Procedure Manual contains 19 policies and procedures, all of which are new policies. This policy and procedure manual has incorporated the previous Cancer Registry and Patient Navigation Policy and Procedure Manuals with major revisions. The pre-existing Cancer Registry and Patient Navigation Policy and Procedure Manuals will be deleted.
ARMC completed the 2020-21 review of this Policy and Procedure Manual and recommends the revisions summarized in Attachment A. Review and update of this manual is certified in Attachment B. The Ambulatory Services - Cancer Program Policy and Procedure Manual, which includes the new policies listed below, is provided in Attachment C:
|
Policy Number |
Policy Title |
|
ONC 100.01 |
Cancer Accreditation |
|
ONC 100.02 |
Staff Credentials |
|
ONC 100.03 |
Multidisciplinary Cancer Case Conference (Tumor Board) |
|
ONC 100.04 |
Genetic Counseling and Risk Management |
|
ONC 100.05 |
Departmental Care Services |
|
ONC 100.06 |
Survivorship Program |
|
ONC 100.07 |
Cancer Registry Quality Control |
|
ONC 100.08 |
Clinical Research Accrual |
|
ONC 101.01 |
Organizational Structure, Function, and Provision of Service |
|
ONC 101.02 |
Software Reporting Systems |
|
ONC 101.03 |
Data, Documentation, and Reporting |
|
ONC 101.04 |
Cancer Case Identification |
|
ONC 101.05 |
Cancer Casefinding and Suspense |
|
ONC 101.06 |
Cancer Case Abstracting |
|
ONC 101.07 |
Quality Control |
|
ONC 102.01 |
Organizational Structure, Function, and Provision of Services |
|
ONC 102.02 |
Oncology Clinic and Patient Processing |
|
ONC 102.03 |
Support Groups and Educational Resources |
|
ONC 102.04 |
Tracking, Documentation, and Reporting |
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 373 policies, of which one (1) new policy has been added and two (2) policies have major
revisions. The new policy, which is in Attachment D, pertains to gastrointestinal tube insertion and maintenance, enteral nutrition, and gastric decompression in adults. ARMC completed the 2020-2021 review of the policy revisions and recommends the revisions summarized in Attachment E, which pertain to the Quality Assurance and Performance Improvement Plan as well as the screening and management of patients at risk for suicide.
Medical Imaging Policy and Procedure Manual - Policy Reviews
The Medical Imaging Manual contains policies and procedures regarding department organization and function, and patient care practices. The manual contains a total of 143 policies, of which seven policies were reviewed for medication ordering, preparation, administration, and distribution. ARMC completed the 2020-2021 review of policies for contrast and radionuclides as required and recommends the no revisions to the policies, as stated in Attachment F.
Emergency Response Policy and Procedure 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
five (5) policies have minor revisions and forty-four (44) policies have been reviewed with no recommended changes for this review cycle. ARMC completed the 2021-2023 review of this policy and procedure manual and recommends the revisions outlined in Attachment G, which relate to the Emergency Operations Plan, emergency communications, hospital disaster supplies, Ontario Airport repatriation and visitor limitations guidance. Review and update of this manual is certified in Attachment H.
On June 8, 2021 (Item No. 18), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment I.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5465) on June 17, 2021; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on June 17, 2021; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on June 28, 2021; and County Finance and Administration (Matthew Erickson, County Chief Financial Officer, 387-5423) on June 28, 2021.