Plan for Patient Care Services


To provide quality mental health services to the citizens of Maryland in a progressive and responsible manner, consistent with recognized standards of care.

Vision Spring Grove Hospital will be recognized as a national leader for excellence in psychiatric care, research and education.

Guiding Principles

  • Best Practices of Clinical Care and Treatment
  • Collaboration and Teamwork
  • Communication
  • Diversity
  • Efficient and Environmentally Sound Use of Resources
  • Education and Training
  •  Empowerment
  • An Environment that is free of Coercion
  • Humanistic Attitudes
  • Professional Competency and the Highest Ethical Standards
  • Promotion of Patient Rights and Responsibilities
  • Research and Innovation
  • Safe Environments
  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 are organization-wide.

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 participates in the P.I. Program and receives feedback as needed.

Community - The P.I. Department regularly communicates with the following agencies:

Mental Health Administration (MHA) 
Center for Medicare and Medicaid Services (CMS) 
The Joint Commission 

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 complement of staff allows for optimal service delivery.

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. Staffs 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 and Services

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:

  1. To provide a planned, systematic, organization-wide approach by continuously designing, measuring, assessing and improving performance of patient care services.
  2. Improve overall performance by accomplishing our mission, meeting expectations of patients, staff and community while maintaining cost.
  3. Promote processes that encourage and facilitate working together to improve services and performance.  

VI. Plan to Improve Quality of Service

  1. Continue to review Joint Commission, CMS, and community standards and keep current with them in anticipation of our surveys and inspections.
  2. Target customer service as a leading priority with continued emphasis on leadership, accountability and employee empowerment.
  3. Continue to identify opportunities for interdepartmental improvements and implement the processes to achieve these opportunities.
  4. Increase use of technology to save time, improve reporting and make more efficient use of staff.
  5. In accordance with the Hospital's strategic plan, develop plans to improve psychiatric outcomes for all patients.