The primary purpose of the Performance Improvement Department is to ensure the hospital’s readiness and preparation to obtain and maintain certification/accreditation via assistance and consultation to management and staff regarding interpretation and integration of regulatory requirements in the daily operations of the organization. The department acts as a catalyst to promote performance improvement activities through the organization by collecting, analyzing, and disseminating data to assist leaders and departments in making judgments about quality issues, needs for improvement and evaluation of changes implemented. The department facilitates awareness of standards and development skills through facilitation and consultation as requested.

The Performance Improvement Department is under the direction of a Performance Improvement Coordinator who reports to the Chief of Standards Management. Staff includes 3 Performance Improvement Nurses, an Information Processing Assistant II and an Office Assistant.