HSC
PERFORMANCE APPRAISAL – (HSC: PSA|Non-union|Salaried and Hourly, AFSCME)
Note: This form may be used for all performance evaluations and may be customized to meet/reflect the needs of the particular department/unit. Please attach full job description.
Employee Name:
Position Title:
Rocket #:
Date:
Registered Nurse
Department:
Policy #:
3364-25-45
Evaluation Period:
Evaluation Type:
Mid-Probation
Annual
End Probation
Special
Total Average
Weighted Score:
GENERAL SUMMARY: Responsible for performing in a manner that promotes the University of Toledo and/or University of Toledo Medical Center. Evaluations will be based on the
five criteria pillars developed in support of the University’s strategic plan, Directions, 2011.
Total Possible Weighted Score
Your Total Weighted Score
Average Weighted Score(round to the
tenth) e.g. 3.2 vs. 3.266
Pillar 1
Pillar 2
Pillar 3
Pillar 4
Pillar 5
0.50
0.20
0.10
0.10
0.10
RATINGS:
5 - Distinguished Contributor: An employee who regularly exceeded expectations and demonstrated extraordinary performance, including achievement of
objectives and demonstration of core pillars. Personal contributions were recognized and applauded by others.
4 - Highly-Valued Contributor: An employee who consistently exceeded expectations throughout the year, going beyond achievement of objectives and
demonstration of core pillars, anticipating issues, and acting proactively.
3 - Valued Contributor: An employee whose performance met and occasionally exceeded all expectations for achievement of objectives and demonstration of
core pillars.
2 - Improving Contributor: An employee whose performance occasionally, but not regularly, met expectations for achievement of objectives and demonstration of
core pillars in selected areas and requires some improvement. (A rating of 2.0 or lower requires an action plan).
1 - Non-Contributor: An employee whose performance did not meet minimum expectations or requirements of the position. Improved performance is required for
continuation in this position. (This rating requires an action plan).
*The overall performance rating is the average of your rating for each individual core pillar.
CRITERIA PILLARS
Foundation/Pillar 1: Core Responsibility: The employee successfully completes the fundamental
responsibilities of the job description and fulfills the basic expectations of the role. The employee’s daily
actions support the strategic direction of the department/division.
Core Duties: (Insert Job Description. Please see template).
Joint Commission Safety Language: Adheres to hospital policies and procedures as well as
addresses patient safety, performance improvement, and quality of care issues. Able to recognize safety
issues in the department and handles incidents per institutional and/or departmental policies and
procedures. If safety issues were identified; all issues were handled timely and appropriately; promptly
reports any errors or deviations from prescribed regimen of care. Follows all department specific safety
education and training in an effort to create a safe work environment. Department education and training
focus has a direct impact on patient safety and reduces unsafe working conditions for employees.
Reduces adverse results or impact to patient care and the employee. Employee’s attend and follow all
department specific safety education and training in an effort to create a safe work environment.
Pillar 2: Customer Service Excellence: The employee demonstrates a noble commitment to patients,
students and other members of the University community. The employee consistently demonstrates to
patients, students and other members of the University community actions that display the employee’s
commitment to provide relief, support, continuous improvement, problem solving, and customer, patient
and/or student centeredness. Must adhere to UTMC’s Customer Services Values and iCare Principle’s
at all times.
Pillar 3: Nimble and Responsive: The employee demonstrates flexibility and adaptability while also
responding to all requests and inquiries in a timely manner. The employee focuses on moving projects
quickly from planning phase to implementation.
RATING
COMMENTS
Pillar 4: Professionalism and Respect: The employee consistently acts and behaves in a manner that
demonstrates the culture of dignity and respect that is required in a world-class University and Health
Center.
Pillar 5: Communication Effectiveness: The employee communicates with clarity, openness and
transparency, ensuring all stakeholders receives appropriate information at all times.
Core Duties: Template
DIMENSION/CRITERIA (Primary Duties, stated in the job description that
fulfills the Pillar 1/Foundation, and any related accreditation
requirements.) Please complete as appropriate for position
Pillar 1
a. Documentation exists that hospital and departmental required competencies have been met.
b. Regularly demonstrates the ability to exercise critical thinking skills in clinical situations.
c. Adheres to hospital policies and procedures as well as addresses patient safety, performance
improvement, and quality of care issues.
d. Administers medication appropriately by implementing current medical regimen taking steps to
ensure patient safety.
e.
When safety issues are identified; issues are promptly reported and errors or deviations from
prescribed regimen of care are handled timely and appropriately.
f. Demonstrates appropriate knowledge, skills and abilities to provide nursing care.
g.
Makes appropriate and timely nursing assessments.
h. Designs and implement an appropriate nursing plan of care including patient and/or significant
other.
i.
Performs appropriate independent and interdependent nursing interventions.
j.
Assumes responsibility for patient education.
Pillar 2
a. Effectively responds to customer service needs by adhering to “All Hands on Deck” initiatives:
Hourly, Rounding, Responding to call lights, Universal Scripting and Service Recovery.
b. Plans appropriate nursing care and demonstrate effective age and culturally appropriate interaction
Rating (Tally
and enter
average into
Pillar 1/
Foundation).
Comments
with patients, families.
c. Serves as an ambassador of University of Toledo/UTMC in the community, demonstrating our
organization’s values, services and mission.
Pillar 3
a.
Promptly responds to nurse call system and relays information directly and promptly to appropriate
caregiver.
b.
Uses time in cost-effective manner and is a productive member of the nursing team.
c.
Assists in functioning of the working area by completing and assisting with indirect care activities
for patients and staff keeping the areas for which nursing is responsible clean.
Pillar 4
a.Maintains a professional image.
b.Maintains an acceptable attendance record.
c. Reports to work on time.
d. Demonstrates flexibility in work schedule.
e.
Regularly attends unit education offerings and/or continuing education programs. Assists in the
education of the health care team,
f. Actively participates in performance improvement activities as related to job duties.
Pillar 5
a.Documents patient information legibly and in an accurately, and timely manner in accordance with
established guidelines.
b.Uses verbal and written communication to report data concerning patients to appropriate individuals
in an accurate, timely and confidential manner.
*The above list of duties is intended to describe the general nature and level of work performed by people assigned to this role. It is not to be construed as
an exhaustive list of duties performed by the people so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control
the work of employees under his/her supervision.
Supervisor Comments:
Employee Comments:
This appraisal was reviewed with me and I received a copy of it.
Employee Signature
Date
Appraiser Signature, Credentials, and Title
Date
Appraiser Printed Signature, Credentials, and Title
Date
Second level appraiser Signature, Credentials, and Title
Date
(Required unless first level is a Chair or Director)
Second level appraiser Printed Signature, Credentials, and
Title
(Recommended not required)
Please Attach signed Job Descriptions
Copy to employee, manager and original to HRTD
Date