P
1. Integration, Collaboration, Teamwork
2. Innovation, Adaptation and Prioritization
3. Growth and Investment
4. Taking Care of Our Own
5. Cultural Competency
6. High Value and Fiscal Soundness
7. Integrity and Trust
1. Service
2. Financial Health
3. Quality Care
4. Academic Support
5. People
6. Community Health
Refer to website for goals and objectives information http://www.med.umich.edu/i/exec/umhsgoals/
For behavioral descriptions of performance ratings go to (form must be unlocked to use links) http://www.med.umich.edu/mchrd/policy/performance/Performance%20Evaluation%20Rating%20Descriptions.pdf
Scale: N = Not Met A = Approaching S = Solid Performance E = Exemplary
Self
Evaluation
Manager’s
Evaluation
1. Customer Focus: Relates work and job purpose to UMHHC mission and commitment to putting patients and families first.
2. Teamwork: Interacts effectively and builds respectful relationships within and between units and among individuals.
3. Communication: Communicates effectively in ways that enhance productivity and build respectful relationships. Demonstrates active listening, written, verbal, and information technology skills. Shares relevant information.
4. Conflict Resolution: Seeks constructive approaches to resolving workplace issues.
5. Integrity: Adheres to high standards of personal and professional conduct.
6. Adapting to Change: Responds positively to change, showing willingness to learn new ways to accomplish work.
7. Respect for Individuals: Fosters mutual respect and supports UMHS commitment to diversity. Promotes community building and diversity initiatives that help employees learn and respect each others’ differences.
8. Safety: Contributes to a safe and secure environment for patients, visitors, faculty, and staff by following established procedures and protocols as appropriate by job function.
9. Quality: Adopts practices to improve work processes, enhance customer satisfaction and ensure excellence in daily work.
10. Efficiency: Accomplishes work in ways that maximize productivity and available resources while minimizing waste.
Summary of UMHHC Performance Behaviors (Includes supporting comments and areas requiring further development. Use corresponding number where applicable.)
PLEASE TYPE OR PRINT INFORMATION
Clinical Nurse Specialist
Staff Member Name Department Name Employee ID # Job Title / Classification Evaluation Period
Document to be reviewed in September 2007. 09/14/06, Page 1 of 4

THE UNIVERSITY OF MICHIGAN HEALTH SYSTEM
University of Michigan Hospitals and Health Centers
Staff Performance Planning and Evaluation
Guidelines for writing job specific expectations go to (form must be unlocked to used links) http://www.med.umich.edu/mchrd/policy/performance/Guidelines%20for%20Writing%20Job%20Specific%20Expectations.pdf
To add rows, copy and paste an entire row. Document must be “unlocked” to add rows. See guide/website for details.
Self
Manager’s
Scale: N = Not Met A = Approaching S = Solid Performance E = Exemplary Evaluation Evaluation
11. Attendance .
12. Direct Patient Care:
 Serves as a reliable source of information on the latest evidence supporting cost-effective, safe nursing practices.
 Conducts comprehensive, holistic wellness and illness assessments and interventions using established or innovative evidence-based techniques, tools, and methods.
 Identifies and prioritizes nursing care needs for a select population of patients/families and plans patient care conferences and programs.
 Designs and evaluates innovative educational programs for patients, families, and groups.
 Collaborates with the multidisciplinary team using the nursing process to integrate the nursing perspective into a comprehensive plan of care for the patient/family.
 Identifies, collects, and analyzes data that serve as a basis for program design and outcome measurement.
 Evaluates the impact of nursing interventions on fiscal and human resources.
13. Nursing Practice:
 Collaborates with others to resolve issues/reduce barriers related to patient care, communication, policies, resources and outcomes.
 Collaborates with nurses to develop practice environments that support shared decision-making. Creates and revises nursing policies, protocols and procedures using evidence-based information to achieve outcomes for indicators that are nurse-sensitive.
 Leads clinical practice, quality improvement initiatives, research utilization project or conducts research for a unit or a program.
 Collaborate with Educational Nurse Specialists, Educational Nurse
Coordinators and others on content and operational design of orientation, clinical competency, and other formal and informal clinical educational program development.
14. Nurses :
 Assists the staff in developing critical thinking and clinical judgment.
 Creates a nursing care environment that stimulates continuous self-learning, reflective practice, feeling of ownership and demonstration of responsibility and accountability.
 Mentors nurses to acquire new skills, develop their careers and effectively incorporate evidence into practice.
 Provides input for staff evaluation.
PLEASE TYPE OR PRINT INFORMATION
Clinical Nurse Specialist
Staff Member Name Department Name Employee ID # Job Title / Classification Evaluation Period
Document to be reviewed in September 2007. 09/14/06, Page 2 of 4

THE UNIVERSITY OF MICHIGAN HEALTH SYSTEM
University of Michigan Hospitals and Health Centers
Staff Performance Planning and Evaluation
Guidelines for writing job specific expectations go to (form must be unlocked to used links) http://www.med.umich.edu/mchrd/policy/performance/Guidelines%20for%20Writing%20Job%20Specific%20Expectations.pdf
To add rows, copy and paste an entire row. Document must be “unlocked” to add rows. See guide/website for details.
Self
Manager’s
Scale: N = Not Met A = Approaching S = Solid Performance E = Exemplary Evaluation Evaluation
15. Organization/System Leadership: Consults with other units and health care professionals to improve care. Participates and guides institutional groups to enhance the clinical practice of nurses and improve patient outcomes. Develops pilots, evaluates, and incorporates innovative models of practice across the continuum of care. Designs and evaluates programs and initiatives that are congruent with the organization’s strategic plans, regulatory agency requirements, and nursing standards. Participates in need identification, selection and evaluation of products and equipment. Advances nursing practice through participation in professional organizations, publications, and presentations.
16.
17.
Summary of Job Specific Behaviors (Includes supporting comments and areas requiring further development). Use corresponding number where applicable.
Previous year Learning and Self-Development Plan Assessment. Refer to the M-Learning system transcript for specific courses and activities completed. http://mlearning.med.umich.edu/ . List supporting comments and areas requiring further development below.
Competency / Mandatory Requirement Summary – See M-Learning link http://mlearning.med.umich.edu/ to obtain transcript. Required mandatories include: Fire/Safety, Corporate Compliance, Unit Critical Incident Plan, Patient Safety .
Refer to blue folder competency tab for competencies not included in M-Learning.
PLEASE TYPE OR PRINT INFORMATION
Clinical Nurse Specialist
Staff Member Name Department Name Employee ID # Job Title / Classification Evaluation Period
Document to be reviewed in September 2007. 09/14/06, Page 3 of 4

THE UNIVERSITY OF MICHIGAN HEALTH SYSTEM
University of Michigan Hospitals and Health Centers
Staff Performance Planning and Evaluation
Guidelines for the overall performance ratings go to (form must be unlocked to use links) http://www.med.umich.edu/mchrd/policy /performance/Overall%20Rating%20Guidelines.pdf
N A S E
Scale: N = Not Met A = Approaching S = Solid Performance E = Exemplary
If
“N” or “A” used in the overall rating, check problem area(s) listed below. Identify any action plans for UMHHC performance expectations, job specific, or self development areas not listed above.
Job Specific
Action Plan:
Customer Service Communication Effective team / group work Other:
Peer /Customer Feedback(Optional): Use this space to capture feedback that is received throughout the year.
Sources of peer/customer feedback include:

Employee survey results

Patient satisfaction survey results

360 Feedback results
Feedback Summary:

Customer feedback solicited via questionnaire
 You’re Super Awards

Written feedback (i.e. emails) regarding the individuals performance
Annual Learning and Self-Development Plan : The Learning and Self-Development Plan is used to set personal and professional goals which contribute to the staff member’s growth and development. After review of evaluation and peer/customer feedback, identify plan for development. (Examples of developmental opportunities include job-shadowing, coaching, mentoring and training.) Enter all training courses into the M-Learning system. http://mlearning.med.umich.edu/ .
1. Growth Area:
2. Growth Area:
3. Growth Area:
Employee Comments: (Optional)
Date Employee Signature Supervisor Name Supervisor Signature Department
PLEASE TYPE OR PRINT INFORMATION
Clinical Nurse Specialist
Staff Member Name Department Name Employee ID # Job Title / Classification Evaluation Period
Document to be reviewed in September 2007. 09/14/06, Page 4 of 4