MEMORIAL HERMANN HEALTH CARE SYSTEM

							Please provide all the information requested in the application. INCOMPLETE OR LATE APPLICATIONS
WILL NOT BE ACCEPTED.


Name: __________________________________________________________________________________
      Last                                First                   Middle Initial

Address: ________________________________________________________ City/State/Zip: ___________


Hospital: _________________ Department: ________________ Job Title: ___________________________


Date of Employment ___________Years Experience _______________Years in Specialty________________


Home Phone _______________________Work Phone ________________ Cell Phone __________________


Email Address_____________________________________________________________________________


Specialty Certification_______________________________________________________________________


Clinical Coordinator/ Director Signature ________________________________________________________


Clinical Ladder Track _______________________________________________________________________


Highest Level of Education___________________________________________________________________

Are you currently enrolled in school? If yes, what school and
program___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________


Application Checklist:

 Clinical Ladder Advancement Application
   Notice of intent to advance
   Clinical Ladder checklist
   Degree plan, if applicable
   Career development plan, if applicable

1                                                         BHS LVNII Clinical Ladder Application.doc
                                     NOTICE OF INTENT TO ADVANCE

Applicants shall post this notice on their nursing unit of their intent to apply for advancement in the Baptist
Health System Clinical Ladder 30 days prior to submitting an application to the BHS Clinical Ladder Review
Board.

NAME________________________________________________________________________
     LAST                            FIRST                      MIDDLE

CAREER LADDER LEVEL SOUGHT __________________________________________

CURRENT CAREER LADDER LEVEL __________________________________________

PATIENT CARE AREA __________________________________________

CLINICAL COORDINATOR __________________________________________

DIRECTOR __________________________________________


I have completed the requirements for RN____ and I would like your input as my peer for my Clinical Ladder
Application. Thanks in advance for your input.


_____________________________________________                  ______________________
             SIGNATURE                                                DATE

Submit to BHS Clinical Ladder Review Board Office, Executive Offices, 615 Soledad, Ste.100, San Antonio, Texas
78205, Office (210) 297- 1512, Cell (210) 218-8609, Fax (210) 297-0150




2                                                                     BHS LVNII Clinical Ladder Application.doc
                                              LVN Clinical Ladder Quiz


    1. What are the three items that you must fax to 70150 to request that you intend to apply for the clinical
       ladder?


    2. You want to apply for LVNIII, how many specific criteria must you meet?


    3. What is the financial incentive for each level?


    4. Where can you obtain the clinical ladder application?

    5. What are the three reasons why you will meet with your management twice during the clinical ladder
       application process?

    6. You have five years of experience and you enrolled and actively attending a professional nursing
       program, what clinical ladder level can you apply for?

    7. Each clinical ladder level requires specific criteria, how many specific criteria are required for level 2
       and how many are criteria are required for level 3?

    8. You are not attending nursing school, what clinical ladder level may you apply for?

    9. What is the primary goal of the BHS Clinical Ladder Program?

    10. You have completed your clinical ladder application and have your management’s signature to validate
        your application, where will you submit your completed application?




3                                                                    BHS LVNII Clinical Ladder Application.doc
            LVNIII Qualifications and Requirements                                            Validated By
    Met expectations for Overall performance rating on last
    annual evaluation
    3 Years or greater acute care (hospital) LVN experience
    Resume
    No corrective action plan in the last six months
    Letters (2) of recommendation – Director and/ or Clinical
    Coordinator and Peer
    Career Development Plan reviewed within the last 12
    months
    Fulltime or Part-time (worked >1000 hours in the last 12
    months)

                    LVNIII Meets (7) system specific criteria (Please provide documentation to support selected criteria)
    Compassion                                                 Metrics                              Validated By
    Participates in post discharge phone calls                 Minimum of 20 calls/month
    Acts as a unit-based ambassador in last six months         To be determined by management
    Instructor for courses such as BLS                         2 classes annually
    Excellence                                                 Metrics                              Validated By
    Demonstrates clinical practice in more than one clinical Works in 1 areas outside of assigned
    or age-related population                                  float cluster
    Facilitates educational offering for patient population or 2 educational offerings in
    staff                                                      collaboration with management
                                                               annually with attendance rosters and
                                                               supporting documents
    Active member of a professional nursing organization       Membership card and attendance
                                                               roster
    Enrolled and demonstrating progression in a RN program




4                                                           BHS LVNII Clinical Ladder Application.doc
    Excellence                                      Metrics                                    Validated By
    Leads an evidence-based practice change,        2 projects with supporting documents
    performance improvement project, NPSG           attendance rosters, and measurable
    project                                         outcomes
    Safety                                          Metrics                                    Validated By
    Active unit based champion for wound care,      Documentation in management
    core measures, HED, customer experience,        reference letter with six months to
    patient safety, NPSG                            validate
    Stewardship                                     Metrics                                    Validated By
    Measurable participation in a                   Outcome of project, i.e., Pressure ulcer
    system/hospital/unit committee                  incidence and documented in
                                                    management support letter
    Contributes to the successful orientation of    List of orientees employed greater than
    new hires                                       90 days
    Contributes to the successful precepting new    New graduate and nursing student
    graduates and nursing students                  evaluation
    Community                                       Metrics                                    Validated By
    Demonstrates involvement in healthcare          20 hours
    related community service activities annually




5                                                          BHS LVNII Clinical Ladder Application.doc
                                                Career Development Plan

Name: _________________________________________________________ Date of Employment: __________________________

Department/Unit: _____________________________________________________ Current Education Level: ___________________

Job Title: ________________________________ Employee’s Clinical Coordinator/Director__________________________________


                    SHORT TERM GOAL                                                         LONG TERM GOAL
Describe two-year career goals in relation to employee’s current      Describe life-long career goals in relation to employee’s current
job and career with the Baptist Health System                         job and career with the Baptist Health System




Action Plan

Date                 Developmental Objectives                      Experiences/ Education                Completion Date




Management Comments




6                                                                                BHS LVNII Clinical Ladder Application.doc
                                 BHS Degree Plan
Course                                                                       Semester
                                   Course Title
Number                                                                        Hours
                                           Fall 1




                                          Spring 1




                                      Summer 1



                                           Fall 2




                                          Spring 2




                                      Summer 2



                                           Fall 3




                                          Spring 3




                                  Total

Employee Signature ______________________________________________Date ________________

Director Signature________________________________________________ Date ________________

7                                                       BHS LVNII Clinical Ladder Application.doc