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
Appointments for Medical Staff and Advanced Practice Professional Staff Membership and/or Clinical Privileges at Arrowhead Regional Medical Center
End
RECOMMENDATION(S)
Recommendation
Approve changes with the following Membership and/or Clinical Privileges categories requested in Attachment A, as recommended by the Medical Executive Committee:
1. Applications for Initial Appointment - Medical Staff
2. Applications for Initial Appointment - Advanced Practice Professional Staff
3. Applications for Reappointment - Medical Staff
4. Applications for Reappointment - Advanced Practice Professional Staff
5. Completion of Focused Professional Practice Evaluation with Advancement - Medical Staff
6. Completion of Focused Professional Practice Evaluation with Advancement - Advanced Practice Professional Staff
7. Completion of Focused Professional Practice Evaluation for New Clinical Privileges - Medical Staff
8. Completion of Focused Professional Practice Evaluation during Provisional Period - Advanced Practice Professional Staff
9. Request to Release from Focused Professional Practice Evaluation - Advanced Practice Professional Staff
10. Voluntary Relinquishment of Clinical Privileges - Medical Staff
11. Voluntary Resignation of Membership and/or Clinical Privileges - Medical Staff
12. Voluntary Resignation of Membership and/or Clinical Privileges - Advanced Practice Professional Staff
(Presenter: William L. Gilbert, Director, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of these changes to membership and/or clinical privileges will not result in the use of Discretionary General Funding (Net County Cost) as there is no financial impact associated with the appointments of membership and/or clinical privileges.
BACKGROUND INFORMATION
The Medical Executive Committee at Arrowhead Regional Medical Center (ARMC) is required to forward a written report and recommendation to the Board of Supervisors (Governing Body) concerning Medical and Advanced Practice Professional Staff membership, which includes the specific medical practice specialty, Department affiliation, privileges to be granted, disciplinary actions, and any special conditions attached to the membership. Unless temporary privileges have been granted by the Hospital Director, these Practitioners do not have the authority to treat patients in their specialty until the Governing Body approves these memberships or clinical privileges.
The recommendations in Attachment A are based upon review and evaluation of the practitioners’ application, verification of education and training, peer recommendations, hospital affiliation verifications, verification from the National Practitioner Data Bank, criminal background, licensing documentation, and the affirmative recommendation from the appropriate Department Chairman, and Credentials Committee. Upon receipt of the recommendation, the Governing Body shall act on the matter. The Governing Body may adopt, reject, or modify a recommendation from the Medical Executive Committee, or refer the recommendation back to the Medical Executive Committee for further consideration. The Governing Body has final authority for granting, renewing, or denying privileges. Privileges cannot exceed two years. Approval by the Governing Body is required to appoint all practitioners for membership and/or clinical privileges who provide patient care services at ARMC, based on the affirmative recommendation of the Medical Executive Committee.
The recommendations included in Attachment A have been reviewed and approved as applicable by the: Department Chairman, Committee on Interdisciplinary Practice, Credentials Committee, and Medical Executive Committee.
This approval process is in accordance with the Medical Staff Bylaws; Centers for Medicare and Medicaid Services; California Code of Regulations Title 22; and the standards of The Joint Commission.
Approval of the changes to membership and/or clinical privileges in the categories identified in Attachment A provide for the safety, health, and social service needs of County residents by ensuring appropriate patient care services at ARMC.
PROCUREMENT
Not Applicable.
REVIEW BY OTHERS
This item has been reviewed by the Medical Executive Committee (Webster Wong, MD, Chairman, 580-3380) on October 28, 2021; County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on October 29, 2021; ARMC Finance (Chen Wu, Budget and Finance Officer, 580-3165) on November 2, 2021; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on November 2, 2021; and County Finance and Administration (Diana Atkeson, Deputy Executive Officer, 387-5423) on November 2, 2021.