To provide quality mental health services to the citizens of Maryland
in a progressive and responsible manner,
consistent with recognized standards of care
Spring Grove Hospital will be recognized as a national
leader for excellence in psychiatric care, research and education.
Best Practices of Clinical Care
Collaboration and Teamwork
Efficient and Environmentally
Sound Use of Resources
Education and Training
An Environment that is free of
Professional Competency and the
Highest Ethical Standards
Promotion of Patient Rights and
Research and Innovation
I. Scope of Service
The Performance Improvement (P.I.) Department has been
charged with the responsibility to promote patient care to the highest
quality through both the content and delivery of services in a safe, efficient
and cost effective manner. The services offered by the P.I. Department
The Department of Performance Improvement includes the
services of Risk Management and Utilization Review.
Each of these services has a separate program describing their activities
and functions. (See SGHC Policy and Procedure Manual).
Patients - The services offered by the P.I. Department are provided to
all patients. Our patient population includes adult, adolescent and geriatric patients
who require inpatient psychiatric treatment.
Staff - Staff at all levels participate in the P.I. Program and receive
feedback as needed.
Community - The P.I. Department regularly communicates with the following
Mental Health Administration (MHA)
Center for Medicare and Medicaid Services (CMS)
Other State and local agencies as needed
Hours - The P.I. Department is open Monday through Friday, 7:30 a.m.
to 4:00 p.m. However, staff may work varied schedules to accommodate the
needs of patients or the department.
II. Staffing Plan
The following staff are employed in the department:
Director of Performance Improvement - Social Work
Manager - 1 Full Time Employee
Utilization Review Coordinators - Registered Nurses -
2 Full Time Employees and one halftime employee.
Coordinator of Special Programs IV - Risk Manager - 1 Full Time Employee
Physician Clinical Specialist (Psychiatry) -
Utilization Review Specialist - on halftime employee.
Office Secretary II - 1 Full Time Employee
This full compliment of staff allows for optimal service
III. Qualifications of Staff
Qualifications for staff are outlined in the State MS-22
Position Description Form. These are maintained departmentally and in
the Personnel Department.
Initial competency is evaluated during the hospital and
departmental orientation process.
Competency of staff is assessed at least annually using
the Performance Planning and Evaluation Program (PEP) developed by the
State of Maryland. This evaluation process reviews each of the essential
job functions and skills needed to perform the job. Each employee has
an employee development plan as well. This serves to maintain or improve
the employee=s level of competency
and identify areas needing additional training.
Departmental policy requires annual attendance by all
staff of the in-services on Patient Rights, Fire & Safety and Infection
Control. Additionally, all professional staff must be CPR certified.
Staff are encouraged to attend both on and off-ground
training in areas related to their job duties. Release time and financial
reimbursement are also offered to participants as needed. Specific training
needs are based on the results of the employee=s
evaluation, job duties, prior experience and supervisor observation.
IV. Description of Relationships with other Departments
As the services offered by the department are organization-wide,
there is on-going communication between the department and all levels
of staff. Through discussion, chart review, committee attendance, telephone
calls, memoranda and written reports there is continuous feedback between
the department and other hospital staff.
All departments and hospital staff participate in the
Performance Improvement (P.I.) Program. Through an established program,
staff could be involved in P.I. in different venues. This may include
but not be limited to serving as a member of the
P.I. Steering Committee, participating in chartered or unchartered teams or working
on a P.I. project.
The Department Director is a member of numerous hospital
committees as well as the State-wide P.I. Directors Committee. In this
capacity information is shared with MHA and other state facilities.
V. Goals of Department
The goals of the P.I. Department are:
A. To provide a planned, systematic, organization-wide
approach by continuously designing, measuring, assessing and improving
performance of patient care services.
B. Improve overall performance by accomplishing our mission,
meeting expectations of patients, staff and community while maintaining
C. Promote processes that encourage and facilitate working
together to improve services and performance.
VI. Plan to Improve Quality of Service
A. Continue to review Joint Commission, CMS, and
community standards and keep current
with them in anticipation of our surveys and inspections.
B. Target customer service as a leading priority with
continued emphasis on leadership, accountability and employee empowerment.
C. Continue to identify opportunities for interdepartmental
improvements and implement the processes to achieve these opportunities.
D. Increase use of technology to save time, improve reporting
and make more efficient use of staff.
E. In accordance with the Hospital=s
strategic plan, develop plans to improve psychiatric outcomes for all