REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
November 15, 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 D):
1. Emergency Response Policy and Procedure Manual
2. Environment of Care 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 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 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 manuals 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 review all ARMC policy manuals. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Emergency Response Policy and Procedure Manual - Review and Update
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 49 policies, of which one policy has a major revision. The major revision pertains to Policy No. 5040.02 relating to visitor restrictions which was put in place as a result of COVID-19. Because the California Department of Public Health has removed the visitor restrictions, the policy is no longer needed and will be retired. The manual also contains a minor revision to update the Table of Contents as a result of the retirement of Policy No. 5040.02.
ARMC completed the 2022 review of the Emergency Response Policy and Procedure Manual and recommends the revisions summarized in Attachment A.
Environment of Care Policy and Procedure Manual - Review and Certification
The Environment of Care Policy and Procedure Manual contains policies essential to safety of
patients, staff and visitors at the hospital. The manual contains 76 policies, which were reviewed with no recommended changes, as set forth on Attachment B. Review and update of this manual is certified in Attachment C.
On October 4, 2022 (Item No. 10), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment D.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on October 18, 2022; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on October 24, 2022; Finance (Jenny Yang, Administrative Analyst, 387-4884) on October 25, 2022; and County Finance and Administration (Diana Atkeson, Deputy Executive Officer, 387-5423) on October 25, 2022.