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Sample Employee Performance Review Forms document sample
Document Sample
Table 2 ENVIRONMENTAL DASHBOARD
Team Name: AMBULATORY SURGERY CENTER Year: Coordinator:
INDICATOR ACTUAL PERFORMANCE
RESPONSIBLE
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
LIFE SAFETY
Fire drill(s) conducted
Fire Extinquisher Inservice
Data Submitted By Fire extinguisher inspection
Fire extinguisher inspection
MONTHLY
EMERGENCY PREPAREDNESS
Participate in Mass Casualty Drill
ANNUAL
Internal Disaster Drill
ANNUAL
Full Evacuation Drill
2X YEAR
Code Blue Drill
QUARTERLY
Hurricane Preparedness
SAFETY
Environmental Checklist
# deficiencies
Leadership Checklist
# deficiencies
# of unprotected pipes under sinks
# of employee injuries
SECURITY
Improved Customer
Data Submitted By
Data Submitted By
Worker's Compensation Number ofof Vendors not responses
Number unsatisfactory not properly
times exterior doors are
# of # of times exterior lights receiving
# of team members not
wearing name badges
# of criteria not met on
confidentiality questionaire
HAZARDOUS MATERIALS
Data Submitted By HazMat Walk-Through completed
# of team members who do not
know where spill kits are
# of times air quality monitoring
completed
UTILITY
# of essential utility failures
Data Submitted By # of weekly fuel tank
Emergency Generator:
# of times monthly runs meet the
30/50 rule or annual load bank test
Data Submitted By
Data Submitted By
Data Submitted By ##of #timesteam member are
# of times timesmembers performed
of timessemi-annual PMs tested as
# FireHVAC equipment
ofof telephone Inspection
# of medicalTransfer
Automatic gases
Marshall system
elevator
INFECTION CONTROL
# of criteria not met on the
Infection Checklist
Data Submitted By
Data Submitted By # criteria not met on
Boiler Inspections
Surgery Infection Risk
ANNUAL RENEWALS
Fire Marshall Facility/Fire
Extinguisher Inspection
Boiler Inspections
Data Submitted By CLIA License
State Licensure
CLIA Waiver
Pathology License
Bio Hazard Mat. Generator
certificate
Occupational License
A/C Contract maintenance renewal
Surgery ASC License
CATEGORY INDICATOR GOAL
ACTUAL PERFORMANCE
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
The following are sample formats for different kinds of IMPACT CARE indicators. Just highlight the row
numbers beside the appropriate rows (11, 12, 13 and 14 for example) and "Copy". Then go to the IMPACT
CARE sheet tab and highlight the row number where you want to insert the indicator. Press the right
mouse button and choose "Insert Copied Cells". Then change the wording and numbers to suit your
purpose. If there is not a sample in the format you need, either pick the closest one and change it, or,
create your own.
from
to
Sample Department Quality Number of unsatisfactory responses
Monthly Percentage Indicator
from
of of of of of of of of of of of of
to
or or or or or or or or or or or or
- - - - - - - - - - - -
Monthly Percentage Indicator (Expense)
from Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual
to Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget
Var. Var. Var. Var. Var. Var. Var. Var. Var. Var. Var. Var.
- - - - - - - - - - - -
- - - - - - - - - - - -
from Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual
to Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget
Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D
- - - - - - - - - - - -
- - - - - - - - - - - -
Monthly Percentage Indicator (Revenue)
from Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual
to Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget
Var. Var. Var. Var. Var. Var. Var. Var. Var. Var. Var. Var.
- - - - - - - - - - - -
- - - - - - - - - - - -
from Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual
to Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget
Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D
- - - - - - - - - - - -
- - - - - - - - - - - -
Regular Quarterly Indicator
From
to
Quarterly Variance / Percent Indicator (Expense)
from Actual Actual Actual Actual
to Budget Budget Budget Budget
Var. Var. Var. Var.
- - - -
- - - -
Y-T-D Actual Actual Actual Actual
variance
<0% Budget Budget Budget Budget
Y-T-D Y-T-D Y-T-D Y-T-D
- - - -
- - - -
Quarterly Variance / Percent Indicator (Revenue)
from Actual Actual Actual Actual
to Budget Budget Budget Budget
Var. Var. Var. Var.
- - - -
- - - -
Y-T-D Actual Actual Actual Actual
variance
<0% Budget Budget Budget Budget
Y-T-D Y-T-D Y-T-D Y-T-D
- 0 0 0
- #DIV/0! #DIV/0! #DIV/0!
Sample Department Quality Number of unsatisfactory responses
Monthly Favorable / Unfavorable Indicator
Even Even Even Even Even Even Even Even Even Even Even Even
Updated: 7/22/2010 Page 2 e8fcd58a-83c1-442b-96f7-ba6a7cf628bb.xls
Review of How IMPACT CARE Plans are Developed
A. DEVELOPMENT
1. Identify the work group whose performance is measured by this plan.
2. Identify your key customers.
3. Define the full scope of activities. Ask the following questions
a. What different functions/tasks are performed (be sure to include your
full range of activities).
b. What areas or places do you perform the functions/tasks?
c. What ages and sexes of customers (patients) are served?
d. What team members are required to perform the tasks?
e. At or during what times are the tasks performed?
4. Identify the key activities within your scope of activities.
a. Consider activities which are:
· High volume - performed frequently or affect large numbers
of customers.
· High risk - expose customers to greater chance of adverse
occurrences if not performed correctly.
· Problem prone - in the past have produced problems for
customers or the organization.
5. Write indicators that measure whether or not customer requirements are
met. Place your indicators in the appropriate category. User the template
(disk) for the monitor report format.
REMEMBER: Only indicators prioritized for improvement should
have a goal. Whenever possible, goals should be written
“from ____ to ___”.
6. Team goals should be written in all caps.
B. IMPLEMENTATION
1. If ongoing monitoring and progress toward goals is satisfactory, no further
action is necessary.
2. If not, the following decisions should be made:
a. Does the indicator measure what was intended?
b. Is the goal reasonable?
c. Is the deviation a negative trend or simply a one time special cause
variation?
d. Is there an individual problem?
e. Is there a process to be improved?
f. Does a goal need to be set?
e8fcd58a-83c1-442b-96f7-ba6a7cf628bb.xls
3. Use quality tools such as statistical process control charts, line graphs, bar
graphs, etc., to help visualize trends within an indicator.
4. Complete action plans when goals have been established. Determine
actions that will eliminate root causes(s).
5. During team meetings, be sure to reward and recognize process
improvement, both individual and group.
6. IMPACT CARE reports should be posted on bulletin boards in work areas.
C. RESULTS AND FOLLOW-UP
1. Monitor and assess the effectiveness of actions taken.
2. Continue ongoing monitoring and communication of results, using
Plan - Do - Check - Act (PDCA) cycle of quality improvement.
3. Regularly review IMPACT CARE indicators to determine whether the
priorities for ongoing monitoring should be changed, or whether the
indicators should be revised.
a. Ongoing appraisal
b. Annual appraisal
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BEST PRACTICE
IMPACT CARE
All IMPACT CARE Plans that meet the "Best Practice" model will
include the following standards:
1. All IMPACT CARE Plans must be written in approved format.
2. All IMPACT CARE Plans will have a header with "IMPACT CARE" and the team
name.
3. All IMPACT CARE Plans will have indicators related to our TEAM GOALS for
Service, Outcome and Cost.
4. Team Goals should be written in all CAPS.
5. All indicators must have at least quarterly data.
6. 75% of all indicators should be written as a negative or error.
7. 75% of all indicators should reflect whole numbers, not percentages.
8. All IMPACT CARE Plans will have one service indicator related to error reduction
and show improvement.
9. Goal statements must be written from ____ to ____.
10. All IMPACT CARE Plans will have an action plan when a goal is established.
11. Team Leaders / Directors will meet with the team to review IMPACT CARE
Plans monitoring and improvements and document at least ten time a year.
e8fcd58a-83c1-442b-96f7-ba6a7cf628bb.xls
IMPACT CARE
SELF ASSESSMENT
SCORE
1 = Never
2 = Sometimes
3 = Always
Do you meet monthly to review IMPACT CARE monitoring and
improvements with your team ten times a year?
When you prioritize for improvement, do you establish a goal in each
area for Service, Outcome and Cost?
Are indicators and/or goals written that target the process?
Do you have indicators related to our TEAM goals for SOC? Are
they capitalized in you IMPACT CARE plan?
Do you have action plans when goals are established?
Are you using QI tools (i.e.: Process Flows, Control Charts, Bar
Graphs) for your indicators with goals to monitor for improvement?
Are they available for the team to view?
Are data collection tools in an easily accessible area for team
member participation?
Do ALL team members participate in the IMPACT CARE process?
TOTAL SCORE
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