REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
September 13, 2022
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 H):
1. Clinical Social Work
2. Critical Care
3. Facilities Management
(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 this item will not result in the use of Discretionary General Funding (Net County Cost). Revisions of policies 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.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals 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 manuals 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, as necessary. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Clinical Social Work Policy and Procedure Manual
The Clinical Social Work Policy and Procedure Manual contains hospital-wide policies and procedures required by regulation or determined by ARMC Administration relating to social work at the hospital. A total of 92 policies were reviewed, resulting in the addition of one new policy, the deletion of eight policies, major revisions to three policies, and minor revisions to 61 policies.
The new policy is to establish procedures for Social Service Practitioners (SSPs) facilitating Room and Board placements. The three major revisions are as follows: Policy 029 Issue 1 was revised to be more consistent with the County’s job description and includes an update to the position title from SSP IV to Lead SSP; Policy 070 Issue 5, which outlines the orientation requirements for new staff, includes revisions to the Initial Competency Assessment form (Attachment A) to ensure new and updated department policies are included in the list of required employee assessments; Policy 152 Issue 4 was revised to remove Attachment B - Health Facility Minor Release Report, as the form is no longer relevant to a medical setting and the Authorization for Release of Minor form is already sufficient. All minor revisions were either grammatical or a change in verbiage to reflect our new Electronic Health Record (EHR) system. Any policy that referenced “Meditech” was changed to “Electronic Health Record”.
ARMC completed the 2019-22 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 new policy added to the manual is included in Attachment C, as listed below:
|
Policy Number |
Policy Title |
|
172 Issue 1 |
Room and Board |
Critical Care Policy and Procedure Manual
The Critical Care Policy and Procedures Manual contains policies and procedures regarding department organization and function, and provision of intensive high acuity patient care practices. A total of 53 policies were reviewed, resulting in the deletion of 14 policies, minor revisions to 24 policies, and no recommended revisions to 15 policies. In addition, a minor revision was made to the index. ARMC completed the 2019-22 review of this Policy and Procedure Manual and recommends the revisions summarized in Attachment D. Review and update of this manual is certified in Attachment E.
Facilities Management Policy and Procedure Manual
The Facilities Management Department Policy and Procedure Manual contains policies and procedures regarding the physical environment of the hospital. A total of 87 policies were reviewed, resulting in the deletion of one policy, minor revisions to 51 policies, and no recommended revisions to 35 policies. ARMC completed the 2019-22 review of this Policy and Procedure Manual and recommends the revisions summarized in Attachment F. Review and update of this manual is certified in Attachment G.
The Board has previously accepted and approved the report of review and certification of ARMC Operations, Policy, and Precure Manuals listed in Attachment H.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on August 15, 2022; ARMC Finance (Chen Wu, Finance Budget Officer, 580-3165) on August 19, 2022; Finance (Jenny Yang, Administrative Analyst, 387-4884) on August 23, 2022; and County Finance and Administration (Diana Atkeson, Deputy Executive Officer, 387-5423) on August 23, 2022.