REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
November 16, 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 G):
1. Nursing Department Policy and Procedure Manual
2. Administrative Policy and Procedure Manual
3. Dialysis Department 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 (the Center), The Joint Commission, and other appropriate regulations and guidelines. Per the Center and The Joint Commission, all ARMC Operations, Policy, and Procedure Manuals are reviewed and revised, as necessary a minimum of every one, two or 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:
Nursing Department Policy and Procedure Manual- Policy Revisions
The Department of Nursing Policy and Procedures 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 Policy and Procedure Manual (Nursing Manual) is necessary to maintain compliance with policy and regulatory bodies. The Nursing Manual contains 122 policies and procedures, of which one is new. The new policy is being added to reflect changes in patient care, specifically related to the use of charting and documentation during acute stabilization. ARMC completed the 2021 review of the Nursing Manual and recommends the addition of the new policy as stated in the 2021 Summary of Policy Revisions in Attachment A. The new policy added to the manual is included in Attachment B, as listed below:
|
Policy Number |
Policy Title |
|
529.00 Issue 1 |
Block Charting - Medication Titration Documentation |
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 371 policies, of which two have minor revisions. The first minor revision addresses separation of employment; and the second minor revision addresses the hospital’s Code Blue, team member roles and responsibilities. ARMC completed the 2021 review of the manual and recommends minor revisions to two policies, as summarized in Attachment C.
Dialysis Department Policy and Procedure Manual- Policy Revisions
The Dialysis Department Policy and Procedure Manual contains hospital-wide policies and procedures required by regulation or determined as necessary by ARMC Administration regarding the quality of patient care within this specialty. The manual has a total of 235 policies, of which two policies are new and two have major revisions. The two new policies include Policy 417.00 Issue 1 which explains how to cohort patients who are under testing or have been diagnosed with COVID. The second new policy is Policy 641.20 Issue 1, which provides guidance related to water and the neutralization and disposal of residual acid concentrates. The two major revisions include Policy 641.00 Issue 4 which is updated to meet manufacturer specification with the new centralized bicarbonate system, preparation, and powder mixing. The second is Policy 641.10 Issue 2 which adds an additional step in the mixing of acids during dialysate preparation, per the manufacturer's instructions.
ARMC completed the review of these policies and recommends the revisions summarized in Attachment D. The two new policies being added to the manual are included in Attachment E, as listed below:
|
Policy Number |
Policy Title |
|
417.00 Issue 1 |
Dialyzing and Infection Control with Coronavirus Positive Patients and Persons Under Investigation (PUI) In Outpatient Department |
|
641.20 Issue 1 |
Neutralization and Disposal of Residual Acid Concentrate for Volumes Greater Than (>) 5 Gallons |
Emergency Response Policy and Procedure Manual- Policy Revisions
The Emergency Response Policy and Procedure 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 50 policies, of which one policy has major revisions relating to Visitor Limitations. The changes to the Visitor Limitations policy brings ARMC into alignment with the COVID vaccine verification requirements outlined by the State Public Health Order, specifically addressing visitors in Acute Health Care and Long-Term Care Settings. ARMC completed the 2021 review of the policies and recommends the revisions summarized in Attachment F.
On September 21, 2021 (Item No. 6), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment G.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on October 21, 2021; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on October 27, 2021; and County Finance and Administration (Diana Atkeson, Deputy Executive Officer, 387-5423) on October 28, 2021.