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UNIVERSITY OF MICHIGAN HEALTH SYSTEM
Performance Evaluation Process-Self evaluation with Peer Input
1. The nurse will select a minimum of 3 peers to perform peer review.
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Those selected must be educated in the peer review process.
At least one peer must be an RN.
Each nurse will be asked to evaluate the person on 1-2 different Framework domains, so that all five Framework domains are
reviewed by peers. Clinical Skills and Knowledge domain must be completed by an RN whenever possible.
2. The nurse will submit the names of their chosen peers to the manager that will be completing their performance evaluation. The nurse
distributes 1-2 domains of the peer feedback tool to selected peers.
3. The reviewers will use the current Development Framework Peer Input tool for their appraisal. They will complete their peer tool, sign it
and return it to the nurse within 7 days.
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Peers should circle the appropriate behavioral level. Peer reviewers would be encouraged to support their views with concrete
examples on the right hand side of the page.
Each peer will comment on 1-2 different Framework domains.
4. The peer review forms are returned to the nurse, who shall review the content and summarizes the information on the performance review
form.
5. The nurse will complete the level appropriate self-evaluation portion of the Staff Performance Planning and Evaluation form, with
consideration of the input provided by the peer evaluation.
6. The nurse will submit their completed Staff Performance Planning and Evaluation form and their Peer Review forms to the manager. If
materials are not submitted within two weeks of the established due date, then the managers may proceed with completing the evaluation
process.
7. The manager will review the peer review form, peer summary and self-evaluation and then complete the manager section of the evaluation
form.
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The manager will utilize peer and self evaluations as well as own knowledge of employee performance in determining ratings on the
Performance Planning and Evaluation form.
Rationale for rating other than “meets expectations,” must be provided in the evaluation summary section after each
domain.
The manager will arrange an appointment with the nurse for the performance review.
8. The Peer Review forms will be returned to the nurse following the performance evaluation process, and a copy of the completed
Performance Plan/Evaluation will be given to the nurse.
9. Completed evaluations are given to the administrative assistant for processing.
Final 4/16/04 Perry
Revised 7/15/05, 9/15/06 Jordan-Sedgeman, Minerath
Revised 3/13/07 Professional Development Framework Performance Evaluation Workgroup
*Peers should circle appropriate level
*Peer reviewers would be encouraged to support their views with concrete examples on
right hand side of page
*Return peer review form to the nurse
DOMAIN: Clinical Skills and Knowledge
A
NURSING
PROCESS
Assessment
B
C
Performs
assessment &
identifies appropriate
nursing diagnosis
and/or patient care
standard with
assistance.
Performs focused
assessment of unit
standard patient for
effective patient care
with minimal
assistance.
Independently and
completely performs
focused assessment
to provide most
effective patient care
for a given patient
population.
Recognizes specialty
data.
Nursing Diagnosis
Recognizes data and Identifies key nursing
identifies obvious
diagnoses to address
nursing diagnoses.
physical and
psychosocial/emotion
al areas.
Planning/Implementation/Evaluation
D
E
Peer Input - Comments
Independently and
Exhibits highly developed assessment abilities that
consistently performs exemplify a comprehensive understanding of the total
goal-focused and
patient/family situation.
individualized
assessment when
caring for all patients,
including those with
complex
pathophysiological
and psychosocial
needs.
Prioritizes key
Individualizes nursing Individualizes nursing diagnoses based on assessment
nursing diagnoses to diagnoses based on data and integrates that with the diagnoses & priorities
address physical and assessment data.
of other disciplines in order to provide holistic care.
psychosocial/emotion
al areas.
Practice is guided
Uses evolving clinical Practice is driven by
primarily by policies, experience as a
theory and
procedures, and
guide for practice.
experience.
standards.
Practice relies on
previous experience
for focused analysis
of problems and
solutions with
individual patient
modification in order
to meet outcomes.
Identifies expected
With guidance
Independently
Accommodates
outcomes and
develops,
develops,
unplanned events
nursing interventions implements, and
implements, and
and evaluates/
to meet identified
evaluates plan of
evaluates plan of
responds
diagnoses and
care that recognizes care that recognizes appropriately with
maintain standards of subtle changes in
subtle changes in
speed, efficiency,
clinical practice.
patient’s condition.
patient’s condition
flexibility, and
Evaluates patients
and adapts plan as confidence.
based on basic
needed.
standards.
DOMAIN: Clinical Skills and Knowledge
(continued)
A
Technology
Utilizes standard unit
technology and with
assistance uses
advanced technology
as appropriate.
B
C
Utilizes standard unit
technology. With
guidance uses
advanced technology
as appropriate.
Utilizes standard unit
technology and uses
advanced technology
as appropriate.
D
Practice is driven by an intuitive base and is selfdirected, flexible, and innovative.
Is consistently effective in providing holistic care that
ensures positive change even in the most challenging
patient care situations.
E
Peer Input - Comments
Becomes expert and Takes a leadership role in evaluating technology and its
resource for use of
potential for use.
standard unit
technology and
advanced technology
as appropriate.
Utilizes computer
correctly for basic
functions, including:
- Groupwise
- CareWeb- labs and
radiology results
reporting
- Omnicell
- Mandatory Program
/ Competencies
- Policies and
procedures
Patient/Family
Education
With assistance,
identifies basic
patient/family
learning needs.
Initiates teaching
using patient
teaching protocols,
patient care
standards and critical
paths.
Utilizes computer for Utilizes computer for Becomes resource
basic functions.
basic functions as
for use of computer.
well as reference on
patient conditions
and treatment.
Able to conduct literature search through library
functions— CINAHL, Cochrane, Medline, PubMed.
Identifies basic
patient/family
learning needs.
Initiates and
evaluates teaching
using patient
teaching protocols,
patient care
standards and critical
paths.
Anticipates patient/family learning needs and utilizes a
variety of teaching strategies appropriate to the patient’s
needs. Serves as expert resource and facilitates other
staff in improving patient education. Collaborates with
other disciplines to develop and/or implement patient /
family teaching programs.
Utilizes patient education resources on the
unit.
Accurately assesses
patient/family’s
readiness to learn,
organizes and
executes
individualized
teaching plan,
evaluates patient’s
understanding and
modifies approach as
necessary.
Identifies learning
needs of designated
populations. Works
collaboratively to
develop strategies to
meet these learning
needs.
Seeks out additional Revises and develops patient education
patient education
materials.
resources beyond
unit.
Seeks out challenging patient/family
education opportunities.
Policy/Procedure/Pr
otocols
Identifies location of
and utilizes hospital
policies and unit
procedures and
protocols.
Consistently utilizes
hospital policies and
unit procedures and
protocols.
Demonstrates ease
in application of
hospital policies and
unit procedures and
protocols.
Teaches and
Researches, revises, and develops hospital policies and
functions as a
unit procedures and protocols utilizing appropriate
resources in the
channels and resources.
application of
hospital policies, and
unit procedures and
protocols.
DOMAIN: Clinical Skills and Knowledge
(continued)
A
Promoting Culture
of Safety
Adheres to hospital
policies related to
medication safety:
* Order writing
conventions
*
Correct
administration
considerations
* Double checks and
other established
policies and practices
Familiar with and
follows standards
related to patient and
staff safety.
Documentation
Admission
assessment, flow
sheets, MARs, and
other applicable
documentation forms
are completed in a
timely manner
according to policy
B
C
D
Identifies and
intervenes when
there are concerns
related to medication
safety.
Identifies and
intervenes when
there are concerns
related to medication
safety, providing
feedback to staff
members involved.
Identifies concerns
and intervenes
related to patient and
staff safety.
Anticipates and
Facilitates others related to patient and staff safety; actively works toward
intervenes related to prevention of potential injury.
patient and staff
safety.
Admission
assessment, flow
sheets, MARs, and
other applicable
documentation forms
are completed in a
timely manner
according to policy.
Consults
documentation to
identify trends in
patient status and
enhance continuity of
assessment and
ongoing nursing
care.
Unit expert and
resource on
medications
applicable to their
unit/clinical setting.
E
Peer Input - Comments
Advocates for culture of safety through knowledge,
problem solving, and system changes.
Involved in ongoing Participates in the development of documentation tools,
quality monitoring of standards, and/or policy.
documentation of
nursing care and
patient outcome.
with minimal
guidance.
Please describe a time when you saw me at my very best. What qualities did I display in
this domain?
Please provide your input regarding opportunites for my personal
and/or professional growth.
I have completed the Peer Feeback Class as required by the UMPNC 2004 contract, paragraph 28E, for
participation in peer review process.
Peer Signature &
Date:
*Peer should circle
appropriate level.
*Peer reviewers would be encouraged to support their views with concrete examples on
right hand side of page
*Return peer review form to the nurse
DOMAIN: Therapeutic Relationships: An intentional interactive relationship with patients and families that is caring, clear, boundaried, positive
and professional. It encompasses the philosophy of the institution, empowerment of the care givers and empowerment of the patient/family.
A
B
C
D
E
Peer Input - Comments
Therapeutic
Communication
Recognizes how the Establishes
Possesses clarity on Consistently role
Intuitively uses expert therapeutic communication with
nurse: patient/family patient/family:nurse ones own values and models individualized patient/family.
relationship impacts relationship. Begins how they effect
therapeutic
the patient
to identify how own interactions,
communication
experience.
values impact the
relationships and
based on patient and
patient/family:nurse boundary setting.
family needs.
relationship.
Introduces self as a Registered Nurse and
describes role. Wears identification.
Individualizes
communication
based on
assessment of the
patients and families.
Initiates consultation Shares and promotes collaborative approach to patient
/ leadership with the and family care.
healthcare team to
share and promote
collaborative
approach to patient
and family care.
Establishes open communication.
Empowerment—Nurse, Patient, Family
Recognizes the need Involves patients and Incorporates
for patient and family families in care.
patient/family in
to participate in care.
planning and
implementing care.
Invites patients and Maximizes patient/family participation in decisionfamilies to actively
making and goal setting along the continuum of care.
participate in plan of
care to foster growth
and competence.
Seeks help as appropriate to assess readiness for participation in
care.
Compassion
Actively listens to
patient/family
concerns in a
respectful manner.
Actively listens and
responds to
patient/family
concerns.
Demonstrates
empathy in
interactions with
patients/families.
Plans and provides Intuitive understanding of patient/family experience and
nursing care that
is proactive in providing creative approaches to optimize
promotes intentional comfort and support.
caring.
Shows kindness and caring with
patient/families.
DOMAIN: Therapeutic Relationships (continued): An intentional interactive relationship with patients and families that is caring, clear,
boundaried, positive and professional. It encompasses the philosophy of the institution, empowerment of the care givers and empowerment of the
patient/family.
A
Advocacy and
Ethics
Recognizes,
respects, and
supports
patient/family rights
and maintains
confidentiality.
B
Seeks resources in
response to
situations that have
the potential to
negatively impact
patient/ family
outcomes.
Aware of UMHS patient rights and
responsibility.
Valuing of Diversity with Patients and
Family
C
Mobilizes appropriate
resources in
response to
situations that have
the potential to
negatively impact
patient/ family
outcomes.
Recognizes ethical
issues and seeks
assistance in
addressing them.
D
E
Peer Input - Comments
Challenges situations Challenges and adapts systems to maximize the
and/or decisions that benefits for patient care.
obstruct positive
patient outcomes and
works to reduce
barriers.
Anticipates patient/family needs.
Aware of and values Demonstrates
Seeks to learn about
the diversity in
openness to the
and optimize the
patient and families. uniqueness of others. unique contribution
inherent in the
diversity and culture
of each individual.
Demonstrates
actions that
incorporate the rich
traditions, beliefs,
and values of
patients and families.
Begins to incorporate Begins to explore one’s own biases and how they impact patient
diversity
care.
considerations in
patient care.
Please describe a time when you saw me at my very best. What qualities did I display in
this domain?
Embraces visible and invisible diversity; seeks out
perspectives from those of different backgrounds and
cultures. Integrates understandings of populations into
patient care.
Please provide your input regarding opportunites for my personal
and/or professional growth.
I have completed the Peer Feeback Class as required by the UMPNC 2004 contract, paragraph 28E, for
participation in peer review process.
Peer Signature &
Date:
*Peers should circle
appropriate level
*Peer reviewers would be encouraged to support their views with concrete examples on
right hand side of page
*Return peer review form to the nurse
DOMAIN: Professional Relationships: An intentional interactive relationship with the health care team that is
marked by mutual regard, trust, and active engagement.
A
B
C
D
Collaboration with the Health Care Team
Recognizes role of
Initiates collaborative Recognizes and
Acts as resource to
each member of the communication.
values professional nursing and health
health care team.
collaborative
care team.
communication and
the positive effect on
patient outcomes.
E
Peer Input - Comments
Through shared values and a clear professional identity,
demonstrates and role models an interdisciplinary
collaborative approach to patient care.
Aware of importance Recognizes the
of team collaboration impact of one’s
and with guidance
behavior on others.
begins to initiate
collaborative
communication.
Initiates referrals.
Identifies and utilizes Is sought out by
collaborative
members of the
resources.
multi-disciplinary
health care team.
Monitors referrals.
Participates and/or leads team care conference.
Frequently initiates consults with health
care team.
Actively collaborates with other health professionals in delivering care.
Recognizes need and calls for team
conference.
Valuing
Teams/Teamwork
Identifies self as
Meets professional
member of nursing
commitments
and health care
consistently.
teams.
Begins to generate
trust, respect, and
compassion within
the workgroup.
Seeks assistance
with resolving
conflict.
Takes responsibility for developing
beginning team relationships.
Functions as an
independent and
supportive team
member.
Fosters mutual
Demonstrates team values that orient people to care
regard, respect, and about performance and success of others.
trust.
Provides assistance
to others.
Demonstrates active Recognizes value of conflict in individual and
engagement to
organization learning and growth.
enhance patient care
and promote a
positive workplace.
Demonstrates flexibility.
.
Creates conditions and relationships that promote creative, innovative, and
positive processes and outcomes.
Demonstrates
empathy and
compassion in
interactions with
team members.
Asks for and accepts help when needed.
Approaches conflict Role models behaviors that demonstrate compassion and caring.
.
Acknowledges situations in a
.
Fosters other's
when conflict exists.
constructive manner. development of conflict resolution skills.
DOMAIN: Professional Relationships (continued): An intentional interactive relationship with the health care team that is marked by mutual
regard, trust, and active engagement.
A
Valuing of Diversity
in Team
Aware of and values
diversity in all
members of the
health care team.
B
C
Recognizes own
biases and begins to
demonstrate
empathy as a
member of the health
care team.
Seeks to learn about
and optimize the
unique contribution
inherent in the
diversity and culture
of each individual on
the health care team.
Role models and
Depends on diversity of workforce to enrich and build
helps to establish
great places to work.
group norms that
promote valuing of all
health care team
members.
Readily able to
delegate to UAP
according to the 5
Rights of Delegation.
Recognizes and
values
interdependent
relationships.
Adaptable, flexible, and consistently effective in
delegation.
Facilitates continuity
of care and nursing
work flow through
nurse to nurse
delegation.
Recognizes
strengths of other
team members that
would benefit the
patient and the
team—aligns skill
sets of individual
nurses/UAP to
specific patients.
Demonstrates foresight in anticipating and planning to
meet patient and family concerns.
Delegation
Functions as part of Uses 5 Rights of
nursing team; able to Delegation when
describe and begin to delegating to UAP.
use 5 Rights of
Delegation when
delegating to UAP:
* Right task
* Right
circumstances
* Right
person
* Right
communication
* Right
supervision and evaluation
D
E
Peer Input - Comments
Recognizes value of nurse-to- nurse
delegation.
Successfully organizes and coordinates multiple activities, requests, and
needs.
Develops work process that maximize team
work.
Please describe a time when you saw me at my very best. What qualities did I display in
this domain?
Please provide your input regarding opportunites for my personal
and/or professional growth.
I have completed the Peer Feeback Class as required by the UMPNC 2004 contract, paragraph 28E, for
participation in peer review process.
Peer Signature &
Date:
*Peers should circle
appropriate level
*Peer reviewers would be encouraged to support their views with concrete examples on
right hand side of page
*Return peer review form to the nurse
DOMAIN: Professional Development: Committed to the
professional development of self and others.
A
Self
Engages in self
assessment related
to orientation and
initial learning needs
and seeks out unit
resources to assist in
meeting needs.
B
Engages in self
assessment related
to ongoing learning
needs.
Completes mandatory / competency
requirements during orientation and
annually.
C
D
E
Peer Input - Comments
Sets goals for
knowledge/skill
enhancement within
the practice setting.
Sets goals for
knowledge/skill
enhancement within
and beyond the
practice setting.
Sets goals in self directed manner and actively seeks
out opportunities for knowledge/skill enhancement within
and beyond the practice setting.
Seeks out additional
learning experiences
within practice area
* Unit specific
certifications
*
Consultation with
experts
*
Inservices / rounds
* Collaborating with
multidisciplinary team
Attends
inservice(s)/CE’s
within and beyond
practice area.
Evidence of advancing professional identity (at least
one):
* Certification in specialty
(ACCN, ANCC Speciality Areas)
* Active participation in professional organization - i.e.:
Clinical specialty organizations, UMPNC, MNA, ANA,
UAN
* Active
membership / leadership role in institutional groups r/t
nursing
DOMAIN: Professional Development: Committed to the professional development of
self and others.
A
Contributions to
Others
B
C
D
E
Peer Input - Comments
With guidance,
provides respectful
feedback to
preceptors, peers,
and Manager related
to orientation and
initial learning
experience.
Begins to participate Participate in peer
in providing and
feedback.
accepting respectful
feedback.
Expands knowledge
of the process:
* Formal training authentic,
accountable,
respectful, relevant to
clinical performance
* Identifiable /
attributable (not
anonymous)
Contributes to others
knowledge and skill
development in
practice setting.
Takes a leadership
role in building and
maintaining an
environment where
all team members
thrive.
Works to create and sustain a culture that is supportive
and rewards and recognizes professionalism.
Recognizes
professional
strengths in others
and builds upon
them.
Mentors nurse colleagues in achievement of
professional framework progression.
Shares in/contributes Acts as a clinical resource/liaision beyond the unit
to others
setting
*
knowledge/skill
Speciality resource
development in
* Other units
practice setting,
examples include:
* Conducts inservices
* Develops staff
education tools
* Acts as
interdisciplinary
clinical resource and
informal mentor
May act as preceptor of new and present staff when applicable.
Utilizes own knowledge/skills to improve professional development
environment on the unit.
Please describe a time when you saw me at my very best. What qualities did I display in
this domain?
Please provide your input regarding opportunites for my personal
and/or professional growth.
I have completed the Peer Feeback Class as required by the UMPNC 2004 contract, paragraph 28E, for
participation in peer review process.
Peer Signature &
Date:
*Peers should circle
appropriate level
*Peer reviewers would be encouraged to support their views with concrete examples on
right hand side of page
*Return peer review form to the nurse
DOMAIN Advancing Practice through Innovation and Research: Demonstrates ongoing innovation by reviewing, critiquing and applying
existing evidence to practice. Continually improves practice by applying performance improvement methodologies.
A
B
C
D
E
Peer Input - Comments
Research
Reads clinical
articles.
Reads clinical
articles.
Demonstrates an
Reads evidence
awareness of current based articles related
literature in area of
to area of practice.
practice, including
journal club,
inservices, etc.
Implements change in practice for a population of
patients based on the application of current research
findings and evaluates effectiveness of practice
changes.
Participates in
unit/area based
Continuous Quality
Improvement
projects.
Participates in
unit/area based
Continuous Quality
Improvement
projects.
Identifies individual
patient problems
which require
investigation.
Makes recommendations for changes in practice based
on findings.
Participates in
unit/area based
research, as
appropriate.
Participates in and/or
unit/area
based/institutional
Continuous Quality
Improvement
projects.
Presents at unit
based educational
forums.
Shares findings of Continuous Quality Improvement
projects, such as:
* Unit presentation
*
Rounds
*
Poster
*
Publishing
Applies current literature/ research to problems in
practice area.
Innovation (creative solutions to
everyday problems)
Has knowledge of
and supports
established nursing
improvement projects
/ endeavors in
practice setting.
Actively participates
in established
nursing improvement
projects / endeavors
in practice setting.
Identifies areas for
creative improvement
in practice setting
and seeks out
resources and
avenues to address
them (unit practice
council, content
experts, etc.).
Takes on leadership Independently seeks out opportunities to share
role in relation to
information and influence evidence based nursing
innovations/
practice.
improvements in
practice setting.
Evaluates effectiveness of innovation/practice changes.
Please describe a time when you saw me at my very best. What qualities did I display in
this domain?
Please provide your input regarding opportunites for my personal
and/or professional growth.
I have completed the Peer Feeback Class as required by the UMPNC 2004 contract, paragraph 28E, for
participation in peer review process.
Peer Signature &
Date: