PERFORMANCE APPRAISAL OF INTENSIVE CARE UNIT NURSES

Appraisal Score: ___________ Overall Score: _________Name: ___________________ Employee ID: _________Job Title: _________________ Hire Date: ____________Department: ______________Appraisal Date: ____________Review Period: From: _______ To: _______Appraised by: _____________

Key Responsibilities:Responsible to the Nursing Service Director for the efficient, economical and orderly

administration of the Intensive Care Unit in proper documentation, carrying out orders of the Doctors pertaining to the treatment, maintaining the patient’s dignity during the entire intubations process and during extubation, administration of medicines, comfort and safety of the patient, assisting in the surgical procedures, monitoring of vital signs, exhibit knowledge on Advanced and Basic Life Support and ECG reading, care of the equipments and the cleanliness sterility and orderliness of the Intensive Care Unit. Reports to Nurse Supervisor and Accountable to the Chief Nurse.

Rating Scale*: Level 5 (E) Exceptional

Performance far exceeded expectations due to exceptionally high quality of work performed in all essential areas of responsibility, resulting in an overall quality of work that was superior; and either 1) included the completion of a major goal or project, or 2) made an exceptional or unique contribution in support of unit, department, or University objectives. This rating is achievable by any employee though given infrequently.

Level 4 (EE) Exceeds expectationsPerformance consistently exceeded expectations in all essential areas of responsibility, and the quality of work overall was excellent. Annual goals were met.

Level 3 (ME) Meets expectationsPerformance consistently met expectations in all essential areas of responsibility, at times possibly exceeding expectations, and the quality of work overall was very good. The most critical annual goals were met.

Level 2 (I) Improvement neededPerformance did not consistently meet expectations – performance failed to meet expectations in one or more essential areas of responsibility, and/or one or more of the most critical goals were not met. A professional development plan to improve performance must be outlined including timelines, and monitored to measure progress.

Level 1 (U) UnsatisfactoryPerformance was consistently below expectations in most essential areas of responsibility, and/or reasonable progress toward critical goals was not made. Significant improvement is needed in one or more important areas. A plan to correct performance, including timelines, must be outlined and monitored to measure progress.

*The inclusion of goals is typically a consideration in assessing the overall rating.

KEY RESPONSIBILITIESRATING

COMMENTLEVEL

1LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

HOSPITAL BEHAVIORAL EXPECTATIONSA. COURTESY1. Acknowledges a patient’s presence by making eye contact.2. Addresses calls in a warm professional manner.3. Personalizes conversations by using names.4. Politely answers telephone calls.5. Tackle concerns with co-workers professionally and privately.

B. RESPECT/PRIVACY1. Greets patient in a joyous and respectful manner.2. Announces arrival before entering private patient areas.3. Close curtains for patient’s privacy as appropriate.4. Discusses confidential or sensitive information only with appropriate parties and privately.5. Builds and maintains morale in the workplace.

C. COMMUNICATION1. Listens carefully to orders of doctors and call of patients.2. Exhibit sensitivity to the needs of the patients.3. Keeps patients and families informed about their progress through the system.4. Acknowledge customer concerns immediately.5. Seeks constructive feedback regarding his/ her own practice.

D. RESPONSIVENESS1. Acknowledge call lights within one minute.2. Anticipate the needs of the patient.3. Makes clear, consistent and transparent decisions.4. Distinguishes relevant from irrelevant information.5. Quickly conducts good analyses and searches for best possible solutions.

E. TEAMWORK

1. Take ownership and responsibility for addressing problems.2. Cooperate well with others.3. Take initiative.4. Maintains a good relationship with peers and superiors.5. Actively demonstrates willingness to help others.

F. OPERATIONAL1. Arrives promptly at work.2. Performs dispensing tasks according to accepted standard operating procedures.3. Competently solves operational problems.4. Pays attention to details and takes pride in their work.5. Complies with tasks ably, demonstrating a spare capacity at workload.

NURSING PROCESS

1. Nursing diagnosis and care needs are based on thorough assessment.2. Plans for care are formulated immediately based on identified patient’s needs.3. Nursing care is based on the standards of nursing practice.4. Nursing care is prioritized based on assessment of patient’s immediate condition or needs.5. Significant others are involved in the plan of care.6. Patient education or health teachings are implemented in the care course process.7. Evaluation of the patient’s response to nursing care rendered.8. Patient’s response to care, treatment and interventions are recorded promptly.9. Documents medications, treatments, and nursing intervention on appropriate chart forms.10. Completes Discharge Instruction Sheet as appropriately indicated.(Demonstrates expertise in the following areas)

RATINGCOMMENTLEVEL

1LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

1. ECG Interpretation

2. Basic Life Support3. Advanced Cardiac Life Support4. Pulmonary Machines/ Ventilator Use Diseases:1. Stroke2. Myocardial Infarction & or Ischemia3. Diabetes4. COPD5. Heart Failure6. Hypo/ Hyperthyroidism7. Renal Failure8. Cancer9. Mental Health10. Palliative CareWhat do you particularly value about this Nurse’s input to the successful operation and development of the Practice? (In both clinical and personal terms)

Are there any areas which you would like to highlight as being in need of further development?

General Comments:

Signatures:Employee:_____________________________________ Date: __________

Signature: ___________________________My signature indicates that I have received a copy of this evaluation. ___ I would like to include comments from my self assessment.

Manager/supervisor: Name:______________________________Signature: ____________________________ Date: __________

Department manager: Name: ____________________________Signature: ____________________________ Date: _____________

The employee being evaluated is to receive a copy of the completed evaluation formand one copy shall be placed in the personnel file.