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St.

Peter's
HEALTH CARE SERVICES
2012 PERFORMANCE
PLANNING AND EVALUATION
Name: Heather Harris Employee No. 18550
Title: RN II, Acute/D Job Code: 0835
Corporation: SPHCS Cost Center: 1020 Department: Med/Onc
Reports To: Margaret Cassidy
Evaluation Period From: 9/14/2011 To: 9/14/2012
I. ADHERENCE TO POLICIES AND REGULATIONS
Acceptable Not Acceptable* Not Applicable
1. Annual Compliance Training D D
2. Annual Health AssessmenUTuberculosis Screening (PPD/PPDQ) D
"
3. Annual Update/Orientation D J
   
4. BLS or Other Mandated In-service/Education D D
5. Competency Checklist (attached) D D if
6. Registration/Licensure/Certification D D
7. 360 Feedback Tools and Documentation Audits D D
"Attach separate corrective action plan, if "Low· Needs Improvement.
High - Exceptional
 
"Low- Needs Improvement
II. STANDARDS OF BEHAVIOR
(p. 2+3)
D (21-18) (17.5 -13.5) D (13-0)
Job specific competencies/goals to be re-evaluated (no more than 90 days): __/-------.J__
DEFINITION OF RATINGS
HIGH 3 Performance always exceeds the high expectations of the organization, and assists others in doing this.
2.5 Performance usually exceeds the high expectations of the organization.
MIDDLE
2 Performance consistently meets the high expectations of the organization.
1.5 Performance sometimes meets the high expectations of the organization.
LOW 1 Performance rarely meets the high expectations of the organization. Subject to counseling or corrective action.
0 Performance does not meet the high expectations of the organization. Subject to counseling or corrective action.
"The supervisor and the employee will develop a performance improvement plan to be implemented during the re-evaluation period.
T   
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".t\u..:..... rMAC"lI'-"t',
STANDARDS OF BEHAVIOR
(PLEASE SELECT THE APPLICABLE NUMBER)
STANDARD and
CORE VALUE BEHAVIORS
COMPASSION: Be aware of what
Shares the suffering of someone else is
others; showing experiencing.
empathy and concern
for anyone in distress Asks what one can do
and responding kindly to help; is patient;
and sensitively. responds kindly to
others; says "I'm sorry.'
STANDARDS and
CORE VALUE BEHAVIORS
REVERENCE FOR Be respectful and have
EACH PERSON: good manners.
Shows respect and
consideration for each Accepts people's
person, affirming the differences; honors
sacredness of human others' privacy; says
life. 'please' and "thank
you' and 'excuse me';
listens attentively.
STANDARDS and
CORE VALUE BEHAVIORS
COMMUNITY: Be connected.
Works together to
accomplish a task or a Supports diversity;
goal; recognizing offers to help and work
interdependent as a team; shares one's
relationships and knowledge; recognizes
including each person the importance of each
in provision of health team member.
care.
STANDARDS and
CORE VALUE BEHAVIORS
HOSPITALITY:
Creates an
environment where
persons feel welcome
and included, striving
to meet perceived as
well as expressed
needs.
Be welcoming.
Uses AIDET; introduces
oneself and calls
people by name; smiles
and says 'hello' to
people; makes eye
contact; opens doors
and helps with
directions; keeps
environment clean and
safe.
DESCRIPTION RATING RATING DESCRIPTION
Uses non-defensive and non-judgmental o i 3 ALWAYS EXCEEDS - And assists others in doing
communication with co-workers and V
this.
..........................................................................................
customers. Incorporates feedback. Offers to
  2.5 USUALLY EXCEEDS
help. Responds kindly to co-workers and
!
customers.
0
I
..........................................................................................
2 CONSISTENTLY MEETS
0
1
..........................................................................................
1.5 SOMETIMES MEETS
I
0
..........................................................................................
I
1 RARELY MEETS - Subject to counseling or
!
corrective action
0
I
...............................................................................-..........
0 DOES NOT DEMONSTRATE THIS - Subject to
I i
counseling or corrective action
DESCRIPTION RATING RATING DESCRIPTION
Clearly communicates concerns with those O! 3 ALWAYS EXCEEDS - And assists others in doing
directly involved. Talks directly to people i this.
..........................................................................................
without gossiping or spreading rumors.
 
2.5 USUALLY EXCEEDS
Addresses misunderstandings. Acts patiently
I
when asked questions. Answers pages or
D
..........................................................................................
,
2 CONSISTENTLY MEETS
,
returns phone calls promptly.
i
,
..........................................................................................
"
0
,
1.5 SOMETIMES MEETS
I
,
,
..........................................................................................
i
0
i
1 RARELY MEETS - Subject to counseling or
I
corrective action ,
0
I
0
···OOES..   ....·
I counseling or corrective action
DESCRIPTION RATING RATING DESCRIPTION
Is open to other points of view. Is receptive to
OJ 3 ALWAYS EXCEEDS -And assists others in doing
the ideas of others and demonstrates ,i this.
..........................................................................................
willingness to listen with understanding
  2.5 USUALLY EXCEEDS
without interruption. Speaks up when people I
are being excluded. Offers to help other team
01
2
···coNs·isT"ENTly·M·EETS·.. ··.. ··········....··....···..·....·· .....
members.
I
0
I
1.5
..·SOM·ETiM·ES..ME·ET"S· ....·.. ·········..·............·......·..·....·..
!
D
i
..........................................................................................
I
1
I
RARELY MEETS - Subject to counseling or
I
corrective action ,
0
I
..........................................................................................
0 DOES NOT DEMONSTRATE THIS- Subject to
counseling or corrective action
DESCRIPTION RATING RATING DESCRIPTION
Uses AIDET. Role models customer service.
D I
3 ALWAYS EXCEEDS - And assists others in doing
I
this.
 
  2.5
·..USij'All'(·EXC·EE·O·S········..........····......·· ..·.. ·······........
I
!
0
!
2
.. ·coNs·isT"ENTL"y·M·EETS............·····....·......·..........·....
I
0
I
1.5
·..SOMET·IM·ES..MEETS....·........·..·..........········..............·
i
0
, ..........................................................................................
I
1 RARELY MEETS - Subject to counseling or
corrective action
D
j
0
..   ..··
:
I counseling or corrective action
STANDARDS  and 
CORE  VALUE  BEHAVIORS 
EXCELLENCE:  Be proud ofyourself
Takes pride in work, andyourjob.
continuously improving
skills and abilities so Isclean, dresses
that distinctive service professionallyand
benefits those served wears 10 badge; seeks
and work with. opportunitiesto learn
and grow; speaks
positivelyaboutthe
organization; uses
resources wisely.
STANDARDS  and 
CORE VALLIE  BEHAVIORS 
INTEGRITY: 
Keeps one's word and
is faithful to who we
say we are.
Betruthful.
Is honestwithoneself
and others; accepts
responsibilityforone's
actions; avoidslistening
to and spreading
rumors; honorsone's
commitments.
STANDARDS  and 
COREVALUE . BEHAVIORS 
COURAGE: 
Dares to take the risks
one'sbeliefs demand
of us.
Bewilling to take risks.
Stepsoutofcomfort
zoneandtries
something new; isan
advocateforthosewho
need avoice; identifies
and communicates
opportunitiesfor
improvement;resolves
issuesdirectlywith the
people/person involved.
DESCRIPTION 
Followsdepartmentaland/ororganizational
policiesandproceduresincluding dresscode
and universal precautions. Practiceswithin a
cultureofsafetyfocusingon safetyforall-
patients,co-workers and visitors,
Demonstratescompliance with Corporate
Compliancepoliciesandprocedures
applicableto department.
Identifiesways to adjustscheduletomeetthe
needsofthe department. Adheres to
departmentpolicyregarding attendance/work
hours/breaktime, i.e., arrivesand returns
when expected. Speakspositivelyaboutco-
workers, departmentsand theorganization.
Seeksopportunitiesto learn and grow. Uses
resources wisely.
DESCRIPTION 
Completesassignmentsin atimely and
thorough manner. Honorsone's
commitments. Acceptsresponsibilityfor
one'sactions and withoutblaming ormaking
excuses.
,
DESCRIPTION 
Demonstrates initiative(sees something that
needs to be doneand does it).
Makes suggestionsand offersideasfor
improve-mentthatarecosteffective, efficient
and improvecustomerserviceor
quality/safetyofcare/serviceforthe
departmentororganization. Tellsco-workers
andcustomers tosmokein designated areas.
Tells co-workers to follow properhand
washing. Tells co-workers to follow
appropriatesafetypolicies, such as using
minimal liftequipment.
(This total  is  to  be recorded  on  page  1,  Section  II  by checking  the corresponding  box). 
RATING  RATING  DESCRIPTION 
i
ALWAYS  EXCEEDS - And assistsothersin doing 0 3
I
I
this.
I.., 
...........................................................................................  
[g"  2.5 USUALLY EXCEEDS 
.............................................................................................  
2 CONSISTENTLY  MEETS

..............................................................................................  
SOMETIMES  MEETS 1.5

..............................................................................................  
RARELY MEETS - Subjectto counseling or
corrective action
1

..........................................................................................  
DOES  NOT  DEMONSTRATE THIS - Subjectto
counselingorcorrectiveaction
0 0 
RATING  RATING  DESCRIPTION 
ALWAYS  EXCEEDS - And assistsothersin doing
this.
0  
I

.......................................................................................... 
USUALLY EXCEEDS
[](I
y
2.5
..........................................................................................  
CONSISTENTLY  MEETS
0  
I

i 2
..........................................................................................  
0  
j 1.5 SOMETIMES  MEETS 
!
!
 ......
i

1
!
correctiveaction

0   ! 0
I counselingorcorrectiveaction
RATING  RATING  DESCRIPTION 
ALWAYS  EXCEEDS - And assistsothersin doing
j,.
0   !

this.
···USUAL·Ly··EXC·EE·DS································..................
lEf! 
2.5
···coNs·isT·EN·TL·y·jiiEETs····························................
D  I
2

···SOMETiriES··MEETS··································................


!
1.5
!
D
!
!
1
   .......
I correctiveaction

0  
I

0
counselingorcorrectiveaction

11.{
TOTAL 
.....................  
III. JOB SPECIFIC COMPETENCIES
TOTAL TOTAL POINTS JOB SPECiFIC COMPETENCIES
---:-------------------
*Managers must develop a performance improvement plan for those employees scoring less t ~ n   100 points.
    ~                                  
EVALUATOR COMMENTS ON ST. PETER'S HEALTH CARE SERVICES COMPETENCIES:
IV. EVALUATION OF PRIOR G
1.0b'ective:
Description of Achievement:
2.0b'ective:
Description of Achievement:
V. FUTURE GOALS:
1. Objective:
EVALUATOR COMMENTS:
ApPROVALS 
Evaluator:  Margaret Cassidy 
IEvaluator Employee 
J.D.  # 11634  Title:  MQr/Oper/Pat Care-E  Date: 
qlj 0/12,
Next Level Mgmt: 
(Optional) Title:  Date: 
,  , 
Vice President/Executive Director: 
(High - Signature Required) Title:  Date: 
EMPLOYEE'S COMMENTS CONCERNING EVALUATION;  SELF-IDENTIFIED LEARNING NEEDS, SKILLS OR ABILITIES TO DEVELOP;  BARRIERS TO EFFECTIVE WORK AND/OR JOB 
SATISFACTION;  SUGGESTIONS FOR FUTURE PROCESS IMPROVEMENTS. 
EMPLOYEE'S SIGNATUR  :  DATE:  q  20/ J '2
*EMPLOYEE'S SIGNATURE INDICATES THAT THE EMPLOYEE HAS REVIEWED THE COMPLETED APPRAISAL FORM, BUT DOES NOT 
NECESSARILY IMPLY AGREEMENT WITH THE APPRAISAL. 
PERFORMANCE I;VALUATION SUMMARY  
Employee Name:  Heather Harris  Employee No.: 18550 I 
Corporation: SPHCS  
Job Specific Competencies - POINTS:  13Q,   IPlease check appropriate box:  DH  ciM  DL  
Merit Increase:  I Eft. Pay Period BeQinninQ:  I Current Rate:  ,  New Rate:  
Credentials Bonus: $  I Credential:  [Issued Bv:  I  Expiration Date:  
FOR  HUMAN RESOURCES USE ONLY 
Current Review Date:  I Next Review Date:  Performance Salary
Service Premium =$  Ihr. X  Actual  Hrs. Worked in  Review Period =$ 
Retroactive Pay =  Regular/PLlDL Hrs.  X  Ihr. 


Eve/HolidaylWE Hrs.  X  Ihr.X.10 


Night Differential Hrs.  X  Ihr. X.15 


Overtime Hrs.  X  Ihr. X 1.50 


X  Ihr. X 


TOTALRETRo 


HR Data  Entry By:  1Date Rec'd:  1HRIS Operator:  I Date: 
Latest Rev.  12.14.2011 
ANNUAL PERFORMANCE APPRAISAL
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Nome I Fudback    cl: 8 8 6'.

2()'l(, Heather Horris Self 2.9 2.5 3 3 3 3
Peer 1  3 3 3 20%  3 3
2.5 2.5 2.5 Mgr 2.4 2.25 60%
Weighted Average I  2.61 2.61 VJ 2.61 vI  3.01
1.001' 134.8 24.0  134.8 21.0 20.4  21.6  20.8  V.O   J"ob Weight
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80-89%=.95; 
 
   
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#3  Appraisal Scorin9 Grid LvI2-J-4 Update (3).x1s911912012
PATIENT CARE SERVICES  . 
Template Ivl RN2 
ANNUAL EVALUATION SUMMARY
September 2012
Heather Harris RN
Heather is a competent nurse who is deeply committed to providing
excellent nursing care. She frequently goes the extra mile to ensure that
patients receive the care they need. Heather easily develops meaningful
relationships with patients and families.
Heather has a knowledge base that allows her to make appropriate patient
care decisions. She is an important member of the unit tealTI, she asks
questions when she is uncertain, and is always willing to help her peers.
When reporting to the oncoming shift, Heather gives a thorough report, and
the information is accurate. "
When Heather has participated in the orientation of new staff nurses, she is
patient, kind and supportive during their learning. That is clearly appreciated
by our new grads.
Heather is clearly a competent and caring nurse who understands the core
values of St. Peter's Hospital and actualizes thelTI in her everyday practice.
Peggy Cassidy RN MS OCN
Operations Manager 6Pavilion