Mission: UAMS Medical Center CARE Values provides patient centered, cost Compassion effective CARE through a healthcare Positive Attitude system committed to education and Respect research. Excellence Clinical Programs Job Title: NURSING DIRECTOR, QUALITY Job Description Performance Appraisal Reports to: Chief Nursing Officer EMPLOYEE NAME________________________________ (Please Print) Performance areas Overview I. GUEST RELATIONS 25% The Nursing Director has responsibility for development and ongoing evaluation of programs designed to enhance the quality and safety of patient care and the satsifaction of patients and staff within the clinical areas II. SAFETY AND EMERGENCY PREPAREDNESS 10% where nursing is practiced. This includes development, organization, implementation and maintenance of a III. INSTITUTIONAL/PROFESSIONAL STANDARDS 5% performance improvment program that will meet departmental, insititutional, community needs and regulatory IV. PROCESS IMPROVEMENT 5% requirements. This director is responsible for collaboration with nursing leadership and nursing staff through the shared governance model, to implement initiatives which achieve unit and departmental goals related to V. PERFORMS ROLE OF NURSING DIRECTOR 50% safety, quality and satisfaction. The Nursing Director for Quality assumes responsibility for integration of VI. PROFESSIONAL GROWTH 5% nursing initiatives with other functional areas of the hospital to achieve interdisciplinary quality, safety and satisfaction goals. The Nursing Director practices within the limits of the Nurse Practice Act of the State of Arkansas, adheres to institutional policies, procedures, and standards. Qualifications Licensed as a Registered Nurse by the State of Arkansas Corporate Compliance Masters degree in nursing required HIPAA Membership in a professional nursing organization desirable Annual Requirements Module A minimum of five years of nursing experience, preferably in a teaching hospital Willingness to obtain ANCC certification in her/his specialty Ability to communicate with staff, patients, and famililes following CARE guidelines Demonstrate leadership capacity and a philosophy compatible with organizational values Job Specific Competencies Effective verbal and written communication skills 1 2 3 Ages served: (Check appropriate box.) 4 Neonate <30 days 5 Infant >30 days <1yr Pediatrics >1 yrs <13 yrs Adolescent <13 yrs - 18 yrs Adult >18 yrs <65 yrs Older adult >65 yrs I have read and do understand the description of my position with UAMS Medical Center. __________________________________ ___________________________________ EMPLOYEE'S SIGNATURE DATE UAMS MEDICAL CENTER CLINICAL PROGRAMS Job Title PERFORMANCE APPRAISAL EMPLOYEE'S NAME TITLE EMPLOYEE'S DEPARTMENT SAP# EVALUATOR'S NAME TITLE SAP# DATE EMPLOYEE SCHEDULED BEGAN PRESENT DATE OF LAST APPRAISAL POSITION APPRAISAL DATE INSTRUCTIONS: A performance appraisal will be completed annually for each employee. Each indicator on the job description will receive a score of 1 - 5 based on the assessment of the performance criteria. Each score may be determined by percentage, quantity or quality, individually or in combination. A score of three (3) is consdered to be an average score. When an employee complies with the performance criteria, a score of 3 should be given. Any score of 1 or 5 requires a comment by the evaluator. SCORES: -1- -2- -3- -4- -5- QUANTITY: Rarely Occasionally Routinely Consistently Always Needs Meets Exceeds QUALITY: Unacceptable Improvement Expectations Expectations Outstanding UAMS MEDICAL CENTER CLINICAL PROGRAMS (Job Title) NURSING DIRECTOR PERFORMANCE APPRAISAL Key: PT =Posttest V=Verbal PR =Peer Review D= Demonstration CEU = Continuing Education I. GUEST RELATIONS Postest Verbal Peer Review Demo CEU SELF Evaluator PT V PR D CEU Adheres to UAMS Guest Care Guidelines http://www.uams.edu/uh/policy/human resources/hr103.htm Uses appropriate communication (written & verbal) *Uses line of authority when communicating information/problems involving patients/staff. *Communicates accurate and complete information. *Listens and initiates feedback to ensure effective communication. *Ventilates frustrations in appropriate time, place and manner. *Practices discretion (confidentiality) in information shared with patients and peers Availability/Responsiveness *Adheres to department attendance standards by: Observing assigned work hours, reports promptly to duty notifying department of scheduled, unscheduled absences and tardiness per policy. *Responds to staffing needs of unit. Respectful of others *Respects patient's privacy and confidentiality. *Treats patients and visitors with care, compassion and dignity. *Promote positive image of University Hospital. *Assist other staff members in completing job assignments. *Being cooperative and pleasant to co-workers. *Respond to co-workers needs. Takes proactive approach toward customers. *Shows courtesy toward visitors by being pleasant and helpful on the telephone or in person (introducing self, making eye contact and calling others by name). *Assist patients and visitors with information and/or solutions to problems. *Helping or offering assistance to patients, visitors and staff who look confused. GUEST RELATIONS SCORE 0 0 Comments: II. SAFETY AND EMERGENCY PREPAREDNESS Postest Verbal Peer ReviewDemo CEU SELF Evaluator PT V PR D CEU Adheres to UAMS patient safety plan http://www.uams.edu/uh/policy/administration/a406.htm Complies with safety instructions *Adheres to safety standards related to equipment and electrical safety, infection control and OSHA requirements. *Knowledgeable regarding role in emergency codes and procedures. *Completes all mandatory competency requirements annually. Observes safe work practices *Assumes responsibility for personal safety by using proper body mechanics, universal precautions and proper handling of hazardous materials. *Responds in emergency situations. Provides input on safety issues Promotes a safe work environment *Intervenes in unsafe situations by taking action. *Documents in PSN System SAFETY SCORE 0 0 Comments: Approved 7/03 3 III. INSTITUTIONAL/PROFESSIONAL STANDARDS Postest Verbal Peer ReviewDemo CEU SELF Evaluator PT V PR CEU D Adheres to UAMS Code of Conduct http://www.uams.edu/adminguide/win04401.html Adheres to Admin Guide, Clinical Programs and Department policies http://www.uams.edu/uh/policy/pp-toc.htm Adheres to Clinical Program and Departmental dress code standards http://www.uams.edu/uh/policy/human resources/hr204.htm *Complies with dress code policy including wearing UAMS ID badge and demonstrates a professional image in appearance Works effectively with team/work groups and others to fulfill UAMS Mission *Serves as resource person to support department members in performance of duties Adopts practices to improve work processes, enhance guest satisfaction and reduce wastes and costs. *Notifies appropriate staff members of problems requiring prompt intervention. *Identifies and reports areas where cost effectiveness can be implemented within the department. *Utilizes department supplies, equipment and services appropriately Protects confidential information *Adheres to UAMS policy in managing all communications and handling of health care records to prevent improper disclosures and to protect patient confidentiality. *Protects health information that is used/disclosed in any form (electronically, paper or oral) in practice. STANDARDS SCORE 0 0 Max Possible score Comments: IV. PROCESS IMPROVEMENT Postest Verbal Peer Review Demo CEU SELF Evaluator PT V PR D CEU Participates in ongoing hospital performance assessment and process improvement. http://www.uams.edu/UH/policy/administration/a601.htm Ensures continuing department performance assessment and process improvement. Creates work processes to enhance customer satisfaction and reduce waste. Reviews trends/issues from patient safety net Develops, organizes, implements and evaluates nursing quality, safety, and satisfaction programs. 0 0 Comments: Approved 7/03 4 V. PERFORMS ROLE OF NURSING DIRECTOR Postest Verbal Peer ReviewDemo CEU SELF Evaluator PT V PR D CEU V.1. DIRECTS AND PARTICIPATES IN THE DEPARTMENT OF NURSING/UAMS MEDICAL CENTER ORGANIZATION Meets with area CSM as a group or individually on an ongoing basis Documents attendance at 75% of Nursing Leadership meetings Available for 50% of called peer review meetings Manages respective division in congruence with goals, objectives and standards of the department/campus Participates in the functioning of the Department of Nursing as a member of designated Councils, ad-hoc committees, etc. Interprets and communicates the Nursing Department philosophy and incorporates into practice Participates in nursing administrative and dept/unit level decision making and strategic planning for the organization Keeps informed of changing standards and regulations appropriate for each nursing area of responsibility Assumes responsibility for the Department of Nursing in the absence of the CNO, Patient Care Services Comments V.2. FOSTERS A CLIMATE CONDUCIVE TO EDUCATIONAL EXPERIENCE FOR ALL STUDENTS AND STAFF Participates in the provision of learning experiences for students by acting as a resource Collaborates with educators and staff in evaluation of students Provides for administrative, management and leadership experiences for managers, staff and students Comments: V.3. DIRECTS THE UTILIZATION OF THE DEPARTMENT OF NURSING GOVERNANCE SYSTEM FOR PROBLEM SOLVING, IMPROVEMENT OF NURSING PRACTICE AND EXPLORATION OF ISSUES AND POLICY DEVELOPMENT Participates as a representative or resource on a council Fosters staff participation in the governance system Selects policies and procedures that facilitate achievement of organizational goals Integrates nursing policies with organizational policies Comments: Approved 7/03 5 V. PERFORMS ROLE OF NURSING DIRECTOR Postest Verbal Peer Review Demo CEU SELF Evaluator PT V PR D CEU V.4. DIRECTS IMPLEMENTATION OF CLINICAL PROGRAMS AND DEPARTMENT OF NURSING STANDARDS Refers to manuals to validate policy decisions Serves as a resource to other departments in policy decisions Formulates and administers policies and procedures for each nursing division Participates in completion of annual review of all nursing policies and procedures Comments: V.5. FACILITATES THE ONGOING EVALUATION AND INNOVATION OF SERVICES PROVIDED BY ORGANIZED NURSING SERVICES AND THE ORGANIZATION AS A WHOLE Evaluates quality of nursing care through direct observation and data collection Utilizes input from patients, families, physicians and peers regarding care received and staff performance Evaluates the implementation and use of standards of patient care to achieve evidence based outcomes Initiates the patient complaint reporting system and documents actions taken and outcomes Collaborates with other disciplines in promoting, planning and implementing optional patient care as defined by evidence based outcomes Assures assessment of age specific needs for patients Comments: V.6. OVERSEES THE PARTICIPATION IN PLANNING AND MONITORING THE BUDGET FOR DEFINED AREAS Coordinates budget planning, implementation and monitoring for division in collaboration with CSMs Implements cost containment practices and evaluates effectiveness Provides written analysis and justifications for budgetary deviations on a monthly basis Evaluates needs for capital equipment and prepares formal justification Assists in development and monitoring of staffing standards utilizing Quadra Med data: Analyze staffing statistics monthly, reviews cost of overtime and supplemental staffing monthly, assures appropriate staffing levels each shift for acuity/productivity Responsible for educating managers and staff regarding effective fiscal practices Solicits input from Medical Directors/Chairmen of Departments for budget planning Coordinates employee promotions for designated areas Comments: V.7. PROVIDES AN OPPORTUNITY FOR PROFESSIONAL GROWTH AND DEVELOPMENT OF STAFF MEMBERS Provides the opportunity for discussion and feedback regarding individual developmental needs Provides a written evaluation of each CSM based on performance expectations Collaborates with CSMs in the counseling of employees with potential or actual performance problems Identifies and documents deficits in employee performance and monitors for improvement in behaviors Facilitates staff development in concert with CSMs Fosters staff participation in formal and informal educational experiences that will promote professional growth Communicates employee performance problems to the CNO Serves as a resource or mentor to other staff/peers for professional development Comments: Approved 7/03 6 V. PERFORMS ROLE OF NURSING DIRECTOR Postest Verbal Peer Review Demo CEU SELF Evaluator PT V PR D CEU V.8. SERVES AS AN ADVOCATE FOR PATIENTS, EMPLOYEES AND PEERS Acts as a resource to staff in planning and implementing care for patients with difficult or complex issues Identifies ethical issues related to unit/patient care and involves health team members in addressing the issues Provides direction and education to staff on the need to maintain quality care Collaborates and supports other managers and ADON in the performance of their duties involving resolution of management problems V.9. SUPPORTS OTHERS IN THE PERFORMANCE OF DUTIES Provides feedback in a private and constructive manner Praises peers on quality job performance Maintains awareness of changing patterns of care that will affect the present shift or other shift Provides nurse consultation services Oversees unit operation and facilitates the use of resources to meet unit needs Comments: V.10. USES CONSTRUCTIVE FEEDBACK TO IMPROVE PRACTICE Accepts constructive feedback and takes corrective actions when needed Completes annual self evaluation and returns to CNO, Patient Care Services by due date Develops annual written goals and plan of action to enhance practice and meet career goals and submits with annual self evaluation Comments: V.11 PARTICIPATES IN THE RESEARCH PROCESS Completes surveys and data collection forms for research evaluation projects Facilitates data collection for research/evaluation projects conducted Assures practice changes occur only after current literature/research findings are incorporated into practice standards Supports, participates in and/or designs nursing research Comments: V.12. PARTICIPATES IN QUALITY IMPROVEMENT ACTIVITIES Keeps informed of quality improvement activities and aspects of care being reviewed Communicates unit quality improvement concerns/issues to QI manager/designee Recognizes actual legal/risk management issues, reports to and seeks assistance for potential problems Assist department QI manager with analysis of annual data to be used in determining direction for improvement Comments: Approved 7/03 7 V. PERFORMS ROLE OF NURSING DIRECTOR Postest Verbal Peer ReviewDemo CEU SELF Evaluator PT V PR D CEU V.13. PARTICIPATES IN RECRUITMENT/RETENTION OF STAFF Interviews and appoints qualified staff Appoints candidates to fill positions, according to hiring process Fosters an environment that enhances productivity Reviews turnover rate quarterly and discusses with CSM Keeps staff current on intra-and interdepartmental changes Fosters a unit environment in which both staff and patient problems may be expressed and solved as they occur and while they are relevant Collaborates with CSMs upon request regarding appointments to unit positions Serves as a preceptor for newly appointed Nursing Directors/CSMs ROLE PERFORMANCE SCORE 0 0 5 Max. Score Possible 0 0 Comments: VI. PROFESSIONAL GROWTH Postest Verbal Peer Review Demo CEU Criteria attached SELF Evaluator PT V PR D CEU Holds membership in a nursing organization Participates in organization Takes active part in organization, such as committee chair or office Obtains and maintains national certification in area of expertise Participates in continuing education and completes 48 hours annually of staff development activities in professional/institutional advancement PROFESSIONAL GROWTH SCORE 0 0 Comments: Employee Comments: Evaluator Comments: Approved 7/03 8 Administrative UAMS MEDICAL CENTER CLINICAL PROGRAMS (Job Title) PERFORMANCE APPRAISAL SECTION SECTION TOTAL SECTION MAX FROM EACH VALUE SECTION Rate Employee's Overall Performance VALUE POSSIBLE SECTION WEIGHT SCORE I. GUEST RELATIONS (25%) 125 25 0 5 0 SAFETY AND EMERGENCY PREPAREDNESS II. 50 25 0 2 0 (10%) INSTITUTIONAL/PROFESSIONAL STANDARDS III. 25 30 0 0.83333333 0 (5%) IV. PROCESS IMPROVEMENT (5%) 25 15 0 1.66666667 0 V. PERFORMS ROLE OF DIRECTOR (50%) 250 65 0 3.84615385 0 VI. PROFESSIONAL GROWTH (5%) 25 10 0 2.5 0 OVERALL SCORE 0 RECOMMENDED MERIT INCREASE Classified Conversion: 500 - 426 =3 exceeds expectations 425-300 =2 Satisfactory 299-100 = 1 Unsatisfactory COMMENTS: EMPLOYEE’S SIGNATURE / DATE EVALUATOR’S SIGNATURE / DATE I acknowledge that this performance appraisal was discussed with me. Administrative Signature does not necessarily mean agreement.
Pages to are hidden for
"Demo of Self Employee Performance Review"Please download to view full document