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.
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
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
II. Staffing Plan
The following staff are employed in the department:
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.
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
VI. Plan to Improve Quality of Service
201 W. Preston Street, Baltimore, MD 21201-2399
(410) 767-6500 or 1-877-463-3464