1 OO17: Performance appraisal tools, if used, and all associated peer evaluation tools for staff nurses and nurses leaders. Include frequency of evaluation. If the organization uses multiple versions of these tools, provide a representative sample for all levels of nurses. (EP20) Annual Performance Appraisal Tool and Process Riverside Medical Center uses performance management software, called Halogen, for annual performance appraisal completion and tracking. Halogen is managed by our Human Resources (HR) department and we have used this application since 2008. (Prior to 2008, we used paper forms for all employees’ performance appraisals.) A link to Halogen is on our organizational intranet, called Rivernet. We also use Halogen as our job description software. This dual purpose is very efficient, available via a computer to all employees, and eliminates paper. (When Educational Services staff receives a hire notification from HR, they send an email with information and an attached job description/performance appraisal to the new employee prior to orientation. This information has already been shared in pre-employment interviews.) Halogen has some very useful features. For example, all employees can journal in the system throughout the entire performance appraisal/evaluation year. These performance notes can be very helpful for non-management staff and management staff. The employee can click in a checkbox to allow the manager to view these comments, or can choose to keep them private. The employee can also view past appraisals. Management staff can also send an appraisal to another manager, which is a useful option when the employee works in more than one department or has transferred from one department to another during the appraisal year. The appraisal year differs according to role. For Directors and executive staff, the appraisal period is from January 1st to December 31st. For all other employees (such as direct care nurses, team leaders, and managers), the appraisal period is from July 1st to June 30th. The manager completes the employee’s Halogen appraisal. Then, a face-to-face the performance appraisal meeting is scheduled. In most departments, managers post schedules on office doors and employees sign up for a ½ to 1 hour appraisal. During that time, the two discuss performance, competency, and goals. Attendance is also monitored. At the end of the appraisal both employee and manager electronically sign off on the appraisal. The components of the appraisal follow. The percentages shown in parentheses are the weight of each section in the final appraisal score. Note that only four sections (in italics) figure into the final rating: • • • •

Global (Leadership or Employee) Standards (Leadership for Directors and above) (32%) Position Responsibilities (Essential Functions) (40%) Equipment Competencies Goals

2 • • •

Developmental Plan (complete only if employee rated Needs Improvement in any section) Mandatory Competencies and Requirements (such as Life Safety Competencies) (5%) Attendance (23%)

Global standards and position responsibility performance are scored on a 1 to 4 scale as follows: 4 = Consistently Exceeds Expectations 3 = Meets and Sometimes Exceeds Expectations 2 = Meets Expectations 1 = Needs Improvement Position responsibilities and equipment use are also rated on employee competency, which is the knowledge base employees have on the position responsibility or equipment. The person completing the performance appraisal can select from the following competency ratings: 4 = Demonstrated competency of this subject matter, can also verify others’ competency 3 = Demonstrated competency of this subject matter 2 = Demonstrated competency of some of this subject matter; needs further orientation/education. 1 = Lack of understanding of this subject matter. For equipment, the manager must also indicate how competency was demonstrated: PR = Policy Review VC = Video/CBT P = Presentation O = Observation T = Test/Other N/A = Not applicable Performance ratings indicate how the employee performed, while competency ratings are indications that the employee knows how to practice or use equipment. Both components are mandatory. Life safety requirements are scored as either completed or not completed. All employees are asked to provide two to three goals for the coming year. Goals are not scored at the subsequent summative evaluation, but are used to help employees identify the accomplishments they would like to achieve. The Halogen application automatically calculates final performance scores: Consistently Exceeds Expectations = 3.7 – 4.0 Meets and Sometimes Exceeds Expectations = 3.0 – 3.6 Meets Expectations = 2.0 – 2.9

3 Needs Improvement = 0 – 1.9 The final rating is then used to determine if an employee will get an increase in salary (exempt or non-exempt employees), which is usually calculated as a percentage above the employee’s current salary. This percentage may change from year, and is announced to leaders in May so they can share this information with their employees. For example in July of 2009, the increases for the upcoming appraisal year were: Consistently Exceeds Expectations = 3.6% Meets and Sometimes Exceeds Expectations = 3.25% Meets Expectations = 2.75% Needs Improvement = no increase Our appraisal tools vary among job roles. Formative and Summative Direct Care RN Appraisal Tool In 2009, Riverside hospital nursing services implemented a tool along with a new process for performance appraisals/evaluations. To read more about the implementation of these structures and processes and how this tool is used, see EP20. To view the tool used by direct care RNs to track their performance throughout the year, according to the direct care RN position responsibilities, see page 9 of this document. Peers can enter their input in writing onto the staff tool throughout the entire performance appraisal/evaluation period. Peer Review Tools At all levels of nursing, the Halogen software allows for peer review. Any supervisor can set the Halogen appraisal tool to be reviewed and added to by peers. In all leader levels, new leaders are assigned a peer mentor, who works with the new leader regularly during the manger’s orientation period and beyond. These mentor-mentee relationships also last for years. If an incumbent leader begins to struggle with an element of his or her leadership role, a mentor will often be assigned to help the leader with that particular issue. The mentor assignment depends upon the mentee issue. For example, if a manager continues to struggle with maintaining his/her patient satisfaction scores, the manager’s director will ask another manager whose patient satisfaction scores are strong, to work with the struggling manager. An action plan is written and followed to monitor the struggling manager’s progress. A new manager of our 2ICU has benefited greatly from her mentor’s guidance. She said the value of the peer/mentor relationship provides a comfort level in the “new manager world,” and values her peer manager as a “resource and expert and confidante” to help her grow in her new role. Peer review is ongoing during this time as the mentor provides the mentee with guidance in the new role. Peer review through mentorship is also done in this way at the direct care nurse level. In addition to this type of peer review, unit-specific peer review processes are also used.

4 These forms vary according to the focus of the peer review. The frequency of peer reviews varies, according to the performance/competency need on the unit. To view a sample of the forms, click on the name of each form. An explanation of the form is included and the first 3 forms are included at the end of this origanizational overview item. Form Name 2ICU VAP Peer Review ER Specimen Collection Peer Review 3 Med Tele Peer Review Peer Review Council Commitment Form RMC Confidentiality Reminder

Preceptor Feedback to Nurse for Peer Review

Form Use These are the competency tracking forms for the specific peer review projects for 3 of our units. All members of the unit-specific peer review council sign this form. All members of the unit-specific peer review council sign this form, as a reminder of confidentiality related to performance appraisals/evaluations. This form is used by nurses in the unit to provided feedback to the Practice Council on the experience with the unit-specific peer review council.

Annual competencies on a variety of topics and/or equipment are also done in inpatient nursing units or in a central location such as a classroom in Educational Service. Direct care nurses, clinical nurse specialists, and/or Educational Services staff are the peer reviewers. Criteria for being a peer reviewer include designation by the unit manager and a score of 4 on the competency section of the annual performance appraisal. These competencies may be done annually, every two years, or once if this is a new skill or equipment for a unit. Again, direct care staff serves as peer reviewers. A sample of some of these peer-reviewed competencies are listed below and the first two can be viewed at the end of this organizational overview item. Form Name 5ICU RN Age Specific Competency Checklist

Sheath Removal Checklist

ICP Monitoring Checklist 5ICU Critical Care Competency Skills Day Checklist

Form Use This form is completed by RN peers on 5ICU annually. Age specific competencies are done an annual basis and are completed by RN peer reviewers on each unit. This form is used to train and assess competency of RNs who might transfer from unit to another. This would be done one time. These are example of peer review tools used during a unit competency day.

5 Case studies are also done in the Practice Council. There is not a specific tool the council uses; members use guidelines in evaluating a nursing practice issue. The form explaining the case study peer review and the guidelines for reviewing a case follows: RMC Practice Council Case Review Purpose of Case Reviews To provide the structure, process, and outcomes for evaluating specific, unexpected or unintended outcomes of care in terms of efficacy, efficiency, ethics, quality, and safety. Overview of Structure The Practice Council meets once a month. Case Reviews may be regular agenda item each month, for issues or concerns with delivery of care. Case Reviews will not replace RMC structures and processes for FMEA (failure modes and effects analysis, RCA (root cause analysis), or employee-specific disciplinary action. Immediate consultation from the Quality & Safety Council, EBP/Research Council, or Professional Development Council is possible since these councils meet concurrently. Overview of Process and Outcomes 1. Case Submission: Cases will be submitted to the Magnet Office or to the Facilitator of the Practice Council at least 1 week prior to Council Day (2nd Tuesday of the month). More than one case may be submitted each month, with prioritization of cases determined by the Practice Council after consideration of the acuity of the event or concern. Cases may be submitted by any RMC employee or leader. 2. Case Preparation: Magnet Office employees or the Practice Council Facilitator will re-write the case using a standard format that eliminates patient and employee names, to promote objectivity and minimize blaming or preconceived expectations that Practice Council members might have. 3. Case Presentation: Copies of the case write-up(s) will be distributed to the Practice Council by the Practice Council Facilitator at the beginning of each monthly meeting. 4. Case Discussion: The case will be read by all members, and general discussion will ensue regarding the need for additional information, clarification, etc. This is one step in which consultation from other councils may be needed. The time period for this step will need to be carefully monitored by the Facilitator, Chair, and Co-Chair to keep the discussion focused on pertinent facts and to move the discussion forward to the next step. The outcome of this step will be a succinct description and clarification of the issues that need to be analyzed.

6 5. Case Analysis: This step will involve Practice Council members’ analyses of issues using one or more of, but not limited to, the following sources:  ANA Scope & Standards of Practice  ANA Code of Ethics  ANA Nurses Rights  Riverside Policies and Procedures  Lippincott Manual  Standards of Practice for Nursing Specialties  Regulatory Standards (TJC, CMS, IDPH, etc.) The outcomes of this step are identification of the underlying causes of the case issue and a formal write-up of the findings from the case review. A longer-term outcome may include education on, dissemination of, and adherence to accepted standards of practice. 6. Case Recommendations: Recommendations will be based on established care standards, practices, policies, and procedures, and will include references to the sources used in step 5. This will support objective evaluation of the findings and introduction/ review of accepted standards of practice for council members and other Riverside staff. The outcome of this step is a suggested action plan for addressing underlying issues or concerns relating to the case. Action plans may include one or more of the following:  Change in practice, policy, and/or procedure  Education and/or training (initial or remedial) for staff  Addressing behavioral issues, to be carried out by a RMC leader (not the Practice Council) 7. Dissemination of Case Recommendations: Dissemination of recommendations are based on the action plan, and might include referral to:  Human Resources  Educational Services  Patient Safety/Employee Health  One of the other Councils  Patient Care Services Leaders 8. Case Follow-Up  A brief report back to the Practice Council should be done by HR, Educational Services, Patient Safety/Employee Health, PCS Leaders, etc. the following month, or as soon as the concern is addressed/resolved. This brief report will not include any specific disciplinary actions that may have been initiated, but will include, at a minimum, a statement that progress toward the action plan is being made.

7 Summary Riverside Medical Center uses a variety of performance appraisal/evaluation and peer review tools and processes to assess performance and competency of nurses at all levels.

8 Staff Tool-Registered Nurse Job Description and Performance Appraisal Redesign Purpose: The purpose of the job description and performance appraisal structures and processes is to support accountability for professional nursing practice. The performance appraisal process is intended to be a shared evaluation of the nurse’s performance by the nurse and her/his leader (team leader, manager, coordinator, and/or director). The RN Performance Appraisal will reflect the RN’s performance according to the Standards of Nursing Process (Standards 1 – 5) and the Standards of Professional Practice (Standards 6-12). The “Standards of Nursing Process and Professional Practice Form” and “Assessment Criteria Tool” will serve as tools for RNs to evaluate and document their practice. STANDARDS OF NURSING PROCESS (1-5) and STANDARDS OF PROFESSIONAL PRACTICE (6-12) Evidence of performance on Standards 1 – 5 will be found in the nurse’s patient documentation. Evidence of performance on Standards 6 – 12 may be found in a nurses’ patient documentation; through peer review; in nurses’ performance journals; in comments by patients and families, peers, physicians, ancillary staff, etc. Nurses are encouraged to ask questions regarding additional of sources of evidence. Evidence of meeting Standards 6 -12 does not have to relate to the selected patient record; the evidence for Standards 6 through 12 should arise from current 2-4 month formative evaluation period (4 times per year). Directions 1. Nurse manager/team leader will give the “Standards of Nursing Process and Professional Practice Form” and the unit-specific “Assessment Criteria Tool” to the RN: For incumbent staff:  At the beginning of the performance appraisal period each July, and  Following completion of each formative evaluation (total of 4 per rolling year). For newly hired staff:  During unit orientation, then at the end of each formative evaluation period.  Total of evaluations per year might be less than 4 depending on the newly hired RN’s start date. Number of evaluations is at the discretion of the manager/team leader. The purpose of this timing is to provide the RN with the tools for tracking all 12 Standards at the beginning of each evaluation period.

9 2. Nurse manager/team leader randomly selects a patient care documentation episode from patients assigned to the nurse within the current formative evaluation period. Documentation should be selected from a recent patient care episode – preferably within the last 2 – 3 weeks. This process will be repeated 4 times for each RN throughout the 12-month performance appraisal period. The ongoing nature of the performance appraisal affords the staff nurse the opportunity for performance improvement on an ongoing basis. NOTE: This process for newly hired or transferring staff will start when the orientation and probationary period is completed. The number of record reviews should be adjusted accordingly at the discretion of the nurse leader.

3. Nurse manager/team leader notifies staff nurse of the patient documentation record(s) selected for Standards 1 – 5 by providing the account number of the care episode to the RN or by printing the report and giving it to the RN. 4. Within 30 days, the staff nurse will For Standards 1 – 5 (after RN receives account number or paper record from leader) (a) Review his/her patient care documentation (b) Note on the documentation sample or standards form, and on the assessment form how his/her charting supported/did not support each criterion of the Standards of Nursing Process and represented consistent charting practices. The staff nurse may circle, highlight, or check mark each section of the assessment form to indicate all areas were addressed. For Standards 6 – 12 (throughout the current formative evaluation period) (c) Provide written evidence of professional practice for the formative evaluation period (4 per the 12-month performance evaluation year), using the “Standards of Nursing Process and Professional Practice Form” or other documents (such as peer evaluation notes, patient satisfaction feedback, physician letters, yellow connection cards [replaced pink rose forms], peer comments on the standards form, etc.). Your documentation should reflect consistency in meeting this standard. Mentoring – at the end of each of the 12 standards (throughout the current formative evaluation period) (d) As the “13th standard,” mentoring in each of the 12 standards at least once each year is an expectation of professionalism. Mentoring is calculated into your summative performance rating as follows: Number of Standards Mentored in 12-month Period 12 9-11 6-8