MANAGEMENT PERFORMANCE APPRAISAL
Note: This form may be used for managerial/supervisory staff performance evaluations and may be customized to meet/reflect the needs of the particular department/unit. Please
attach full job description. HSC and MC Salaried and Hourly Management and Leadership positions.
Employee Name:
Rocket #:
Position Title:
Date:
Department:
Policy #:
3364-25-45
Evaluation Period:
Evaluation Type:
Mid-Probation
Annual
Sum of the
Weighted
Scores:
End Probation
Special
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
.50
.20
.10
.10
.10
Weighted Score by Pillar
Average Weighted Score (round to
the tenth) e.g. 3.2 vs. 3.266
Page 1 of 12
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. (This rating 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
RATING
COMMENTS
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: (Add key job duties, scope of practice, and other requirements for accreditation or by
law from your job description as an attachment to the end of the document. Please see sample).
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 students, patients and other members of the University community actions that
display the employee’s commitment to provide relief, support, continuous improvement, problem
solving, and customer, student and/or patient 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.
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.
Page 2 of 12
Pillar 5: Communication Effectiveness: The employee communicates with clarity, openness and
transparency, ensuring all stakeholders receives appropriate information at all times.
Page 3 of 12
Management Performance Plan and Appraisal
What were the employee's strengths, areas of improvement and major achievements during the appraisal period?
Are there additional skills, resources, or knowledge that would help the employee more effectively in their current job or enhance his/her
career development? If yes, please list below:
Were there any unanticipated events which occurred during the performance appraisal period that impacted the employee's priorities and
goal achievements? If yes, please describe below, as well as any changes on goals/priorities as a result.
Please set goals and performance objectives for the upcoming appraisal period, which include goals that support the university's strategic
direction. Goals can be listed below or attached to this document.
Page 4 of 12
*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.
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 director)
Second level appraiser Printed Signature, Credentials, and
Title
Date
(Recommended not required)
Is this an addendum to any other performance tool?
□ Yes □ No
Please attach signed job description
Page 5 of 12
Core Duties: SAMPLE
DIMENSION/CRITERIA (Primary Duties and any related accreditation
requirements.) Please complete as appropriate for position.
Rating (Tally
and enter
average into
Pillar 1).
Comments
1. Demonstrates clinical competency and accountability in caring for patients as identified in
unit’s Scope of Care. Demonstrates competency in the care of the patient in the following
stages of the life cycle: infants, children, adolescents, adults, and geriatrics.
a. Documentation exists that hospital required and unit specific competency
requirements have been met.
b. Regularly demonstrates the ability to exercise critical thinking skills in clinical situations.
c. Performs all procedures consistent with approved nursing practices and demonstrates
proper use of equipment/devices pertinent to patient care.
d. Administers medications appropriately and maintains awareness of toward and
untoward effects.
e. Implements current medical regimen taking steps to assure patient safety.
2. Demonstrates appropriate knowledge, skills and abilities to provide nursing care.
a. Makes appropriate and timely nursing assessments.
b. Designs and implements an appropriate nursing plan of care including patient and/or
significant other.
c. Performs appropriate independent and interdependent nursing interventions.
d. Assumes responsibility for patient education.
3. Patient Safety – Required for those subject to JC.
a. Adheres to hospital policies and procedures as well as addresses patient safety,
performance improvement, and quality of care issues.
b. Knowledgeable about patient safety 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.
c. Employee attends and follows all department specific safety education and training
in an effort to create a safe work environment.
d.
Promptly reports any errors or deviations from prescribed regimen of care.
Page 6 of 12
Core Duties: Sample
DIMENSION/CRITERIA (Primary Duties and any related accreditation
requirements.) Please complete as appropriate for position.
4. Responding to unexpected events Competency – Required for those subject to JC.
Rating (Tally
and enter
average into
Pillar 1).
Comments
Assessment method
a. Able to identify types of crisis events.
verbalization
b. Able to verbalize number to contact in case of emergency.
verbalization
c. Able to verbalize necessary follow up process.
verbalization
d. Able to demonstrate response to unexpected events through scenarios.
Role play, verbalization, demonstration
5. Early Warning Signs Competency – Required for those subject to JC.
a. Staff participates in education and training about early warning signs and
protocol.
Assessment Method
Deemed competency via verbalization
b. Able to verbalize/identify types of crisis events.
verbalization
c. Able to verbalize how an early warning sign and how to respond to the patient.
verbalization
d. Able to verbalize number to contact in case of emergency. (How/who to contact)
Verbalization
6. Team Building Competency – Required for those subject to JC.
a. Able to identify what is a team.
Assessment Method
verbalization
b. Able to identify importance of working in a team.
verbalization
c. Able to identify individual role in the team.
verbalization
d. Able to direct team interactions on the job.
observation
e. Cites specific examples of teams that are present in work force and how the
manager influenced the positive outcome of the team.
verbalization
f.
evidence presented to manager/ direct observation
Conducted a team meeting/ activity within the year.
Page 7 of 12
Core Duties
DIMENSION/CRITERIA (Primary Duties and any related accreditation
requirements.) Please complete as appropriate for position.
Rating (Tally and
enter average
into Pillar 1).
Comments
1.
2.
3.
Page 8 of 12
Core Duties
DIMENSION/CRITERIA (Primary Duties and any related accreditation
requirements.) Please complete as appropriate for position.
Rating (Tally and
enter average
into Pillar 1).
Comments
4.
5.
6.
7.
Page 9 of 12
8.
9.
10.
Page 10 of 12
ACTION PLAN FOR IMPROVING JOB PERFORMANCE
This memo is intended to serve as an action plan and is the culmination of a pattern of job performance which is inconsistent with UTMC’s values of
_____________ the department’s expectations for _____________.
I want to work with you and include any resources you feel are not listed here under the specific areas of performance needing development. I recognize that you
may have additional ideas on how to improve your performance. Therefore, I encourage you to provide your own personal improvement suggestions.
Performance Issues
Focus Areas:
Describe a recent incident:
Describe another incident:
Expectations:
The expectation for _____________ is _____________. We have discussed issues involving ______________ on the following prior occasions:
List dates and conversation content here in bullet form.
Page 11 of 12
RESOURCES/CORRCTION PLAN
List resources here. Think outside the box and include not only department resources but also educational materials. Try to think what would be help full the THIS
employee. People learn differently.
Focus Areas:
Describe a recent incident:
Describe another incident:
Expectations:
The expectation for _____________ is _____________. We have discussed issues involving ______________ on the following prior occasions:
List dates and conversation content here in bullet form:
MEASUREMENT
I will be able to monitor your progress in this area by (describe how you will know the employee is on the right track)
Consequences if failure to improve
If you have any further incidents of the same or similar nature within _____________ from the date of this action plan, you may be disciplined up to an including
termination.
Follow up and Personal Commitments
(Department Manager) commits to:
Employee Signature
Date
Manager Signature, Credentials, and Title
Date
Page 12 of 12