exemplary professional practice accountability, … · the form and returns it to the direct...

EP15 ExB Advocate BroMenn Medical Center 1

Exemplary Professional Practice ACCOUNTABILITY, COMPETENCE, AND AUTONOMY

EP15 – Nurses at all levels engage in periodic formal performance reviews that include a self-appraisal and peer feedback process for assurance of competence and continuous professional development.

Example B: Provide one example, with supporting evidence, of nurse leaders using periodic formal performance review that includes a self-appraisal and peer feedback process to enhance competence or professional development. Note: The CNO can also be included for this example.

Self-appraisal and Peer Feedback Process for Nurse Leaders

Performance review is an annual process for nurse leaders (directors) at Advocate BroMenn Medical Center (ABMC). The process is facilitated by an electronic learning management system called Advocate Talent Management System (ATMS). Leadership performance reviews are based on two components. The first component is measureable goals, which comprise 70% of the review. These goals are directly tied to broader system objectives, which are critical to Advocate Health Care’s (AHC) success. The intent of the goal-based review is for all of leadership to be “rowing in the same direction” and working with their peers to achieve organizational goals. A single date for leadership performance reviews is established so all leaders are measured consistently and fairly based on end-of-year results. Performance on a goal determines the number of points received for that measure. Goals are job-specific and appropriate for each role. In 2015, ABMC’s Chief Nursing Executive cascaded appropriate goals from her goal plan to each of her nurse leaders. The weighting of each goal is established based upon CNE and nurse leader input. The second component is the Advocate Behaviors of Excellence (BOEs), which comprise 30% of the review. The BOEs are a set of established behavioral standards that everyone in the organization is expected to model. These BOEs are aligned with AHC’s Mission, Values and Philosophy (MVP) and specifically outline how associates demonstrate the values in action.

Leaders are notified electronically when their review date is approaching and this signals the leader to complete their self-appraisal in ATMS. The leader enters the year end goal results into the system and has the opportunity to add free text comments and explanations for all goals. The leader also provides a self-appraisal of their Behaviors of Excellence. Again, a free text section is available to provide additional detail. When the self-appraisal is complete, it is sent electronically to the leaders’ direct supervisor to continue the process. The self-appraisal comments become a part of the overall performance evaluation.

During the time that the leader is completing a self-appraisal, his/her direct supervisor is seeking peer feedback. A standardized peer feedback form is used to solicit this information. The direct supervisor sends the form electronically to peers who work


closely with the leader, setting a date for the form to be returned. The peer completes the form and returns it to the direct supervisor who requested the feedback.

For this example, a Director completed their self-appraisal and submitted it to Laurie Round, MS, BSN, RN, NEA-BC, Vice President of Patient Services and Chief Nursing Executive, her direct supervisor. Laurie solicited feedback from three directors who work closely with the director being evaluated (Exhibit 15.B.1 Nurse Leader Peer Feedback).

Nurse Leader Competence and Professional Development Enhanced

The self-appraisal, peer feedback and evaluation process are used to enhance competence and professional development for nurse leaders. When the self-appraisal and peer feedback forms are received by the direct supervisor, the supervisor uses both elements to develop the annual evaluation. The direct supervisor has the ability to add comments throughout the appraisal and to note associate strengths, as well as associate areas of development (Exhibit EP15.B.2 Nurse Leader Self-Appraisal and Performance Evaluation).

In addition to the performance appraisal, AHC uses a potential assessment process for leaders. The potential assessment is an electronic process, also in the ATMS, designed to provide associates with the tools and feedback they need to develop professionally and reach their career goals (Exhibit EP15.B.3 Potential Assessment Template). Executive leaders are responsible for rating their director-level associates on potential, in addition to performance. At AHC, the potential assessment is made up of three elements:

1. Advocate leadership competencies

2. Desire for more responsibility

3. Adaptability

These elements help senior leaders to identify director strengths and developmental opportunities beyond what the performance review can offer. They help leaders think about career development and which future roles might be a match for a director’s skill set and interests. The graphic below displays the time frame for the entire process.


(Exhibit EP15.B.4)

Once performance potential ratings have been completed, vice presidents attend a calibration session to review the ratings of their directors. The purpose of this session is to enable open, candid discussion among peer leaders about the performance and potential of the directors within that business unit. These discussions focus on the strengths and developmental opportunities of each rated associate. The information from the session is used to provide the associate with balanced feedback about his or her areas of strength and opportunity.

The one-on-one feedback discussion between the vice president and the director is the most important step in the review process. This discussion is the leader’s opportunity to provide the director with valuable feedback, both about past performance and future growth and development.

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COWORKER/SELF FEEDBACK FORM: Nursing

Your name (optional): Trayce BartleyLeader Receiving Feedback: Lori Harper

Send back to: Laurie Round by 3/10/16 (date).

Please give the leader named above constructive, developmental feedback. Keeping in mind the Behaviors of Excellence shown below, write specific examples

of Strengths and Areas for Learning/Development. Use additional sheets as necessary. Your feedback will be kept confidential and will be summarized for

this leader by his/her manager. You do not have to comment on all of the Behaviors of Excellence.

BOE Rating BOE Descriptor

Be

Responsive

Does not Meet Approaches Meets Exceeds Significantly Exceeds

Timeliness and consideration when addressing communication; attentiveness and compassion to issues andconcerns; adapting to change and role in change initiatives; quality and consistency of service provided byteam; approach to service feedback and improvement opportunities.

Be Respectful


Fair and respectful treatment of all people; appreciation for cultural diversity; management of conflict andcrucial conversations; clear and open communication; building candid and trusting relationships; contributingto a culture of mutual respect; handling of disrespectful behavior.

Be

Professional


Attention to industry and professional trends; application of learning into strategy and decision making;response to tense and stressful situations; adapting to unexpected challenges; representing Advocatepositively; acting in the best interest of the organization; demonstrating integrity and ethics; protectingconfidentiality and privacy.

Be

Accountable


Following through on promises and commitments; monitoring progress to meet deadlines; holding othersaccountable for results; using metrics to manage team performance; assessing impact of KRA outcomes indecision making; emphasizing importance of KRA outcomes.

Be

Collaborative


Managing up other people and groups; reducing anxiety and building alignment; handling of associatesuggestions and perspectives; recognizing individual and team accomplishments; rewarding and motivatingtop performers; partnering with others to improve service; role in cross-functional teams.

Be Safe


Modeling safety behaviors; encouraging error reporting and problem solving, thanking/protecting associateswho raise safety concerns; addressing system issues that may lead to patient or associate harm; providingresources to staff to practice safety first; reinforcing staff safety behaviors; addressing unsafebehaviors/choices; participating and partnering with colleagues in site safety initiatives.

Exhibit EP15.B.1 Advocate BroMenn Medical Center

BOE Strengths:

Be Collaborative

Lori effectively communicates with patients, physicians, leaders, and associates. She finds ways manage up others which helps to motivate and empower

associates and others to perform at their highest level. She is consistently available for her associates, leaders & physicians. She acknowledges their

suggestions and perspective while insuring System alignment. Lori consistently and creatively finds way to recognize top performers in a way that encourages

others to strive for excellence. Lori takes a global view when looking at issues to insure the organizations overall goals are met.

Be Responsive

Lori is always timely with communicating and responding to others requests. She is considerate of others feelings while insuring critical conversations are

held. She demonstrates adaptive and resilient skills which is beneficial in our ever changing healthcare environment. Lori also quickly anticipates her staff

and patient’s needs. She quickly responds appropriately and provides opportunities for feedback from others.

BOE Areas for Learning/Development:

The opportunity exists for Lori to empower RNs in her sphere of influence to embrace their profession by understanding their practice model and how it improves

patient care and outcomes. Doing so elevates nursing and insures future generations will have highly skilled professional nurses caring for them.

Job Accountability Strengths:

Lori demonstrates a high level of clinical aptitude related to overall nursing knowledge and clinical practice. She is respected by her peers and staff. Lori

successfully implements and completes System and Site initiatives. She continually achieves her required goals. She always looks for opportunities to improve

patient outcomes while eliminating waste and cost.

Job Accountability Areas for Learning/Development:

The opportunity exists for Lori to help hospital leadership find new revenue streams and business opportunities. Health care providers traditionally have not

required nurse leaders to be business savvy. Today’s health care environment is changing. Nursing leaders need to be at the forefront ensuring a sustainable

health care model exists that can deliver excellent patient outcomes.

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Your name (optional): Ann FrederickLeader Receiving Feedback: Lori Harper






Be

Responsive

Does not Meet Approaches MeetsX Exceeds Significantly Exceeds

Timeliness and consideration when addressing communication; attentiveness and compassion to issues and concerns; adapting to change and role in change initiatives; quality and consistency of service provided by team; approach to service feedback and improvement opportunities.

Be Respectful

Does not Meet Approaches Meets ExceedsX Significantly Exceeds

Fair and respectful treatment of all people; appreciation for cultural diversity; management of conflict and crucial conversations; clear and open communication; building candid and trusting relationships; contributing to a culture of mutual respect; handling of disrespectful behavior.

Be

Professional


Attention to industry and professional trends; application of learning into strategy and decision making; response to tense and stressful situations; adapting to unexpected challenges; representing Advocate positively; acting in the best interest of the organization; demonstrating integrity and ethics; protecting confidentiality and privacy.

Be

Accountable

Does not Meet Approaches MeetsX Exceeds Significantly Exceeds

Following through on promises and commitments; monitoring progress to meet deadlines; holding others accountable for results; using metrics to manage team performance; assessing impact of KRA outcomes in decision making; emphasizing importance of KRA outcomes.

Be

Collaborative


Managing up other people and groups; reducing anxiety and building alignment; handling of associate suggestions and perspectives; recognizing individual and team accomplishments; rewarding and motivating top performers; partnering with others to improve service; role in cross-functional teams.

Be Safe


Modeling safety behaviors; encouraging error reporting and problem solving, thanking/protecting associates who raise safety concerns; addressing system issues that may lead to patient or associate harm; providing resources to staff to practice safety first; reinforcing staff safety behaviors; addressing unsafe behaviors/choices; participating and partnering with colleagues in site safety initiatives.

BOE Strengths:

I have a great deal of respect for Lori. Lori is a seasoned director, who represents her departments and the hospital well in any interaction. She handles conflict extremely well and always responds with grace when under fire. She is an excellent mentor for nurses wishing to further develop their leadership skills and a champion for nursing as a profession. She is always willing to come to the table for problem-solving and manages others up on a regular basis. She models safety behaviors and the BOEs for others.


Prioritization is critical given the number of projects and demands on Lori’s plate. She prioritizes well, but at times could communicate more clearly or in a more timely manner with other departments when timelines are being adjusted or deadlines are unable to be met.


Appears to represent the hospital in any setting, including system meetings

Quickly addresses clinical and quality of care concerns within her areas of responsibility

Strong patient advocate

Sensitive to the needs of her associates

Innovative and resilient

Excellent critical-thinking skills


I believe an opportunity exists to put a more coordinated approach in place for the review and ongoing management of policies and procedures that are an essential part of nursing practice and/or touch points between nursing and the other disciplines

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Leader Receiving Feedback: Lori Harper Your name (optional):






Be

Responsive


Timeliness and consideration when addressing communication; attentiveness and compassion to issues and concerns; adapting to change and role in change initiatives; quality and consistency of service provided by team; approach to service feedback and improvement opportunities.

Be Respectful


Fair and respectful treatment of all people; appreciation for cultural diversity; management of conflict and crucial conversations; clear and open communication; building candid and trusting relationships; contributing to a culture of mutual respect; handling of disrespectful behavior.

Be

Professional


Attention to industry and professional trends; application of learning into strategy and decision making; response to tense and stressful situations; adapting to unexpected challenges; representing Advocate positively; acting in the best interest of the organization; demonstrating integrity and ethics; protecting confidentiality and privacy.

Be

Accountable


Following through on promises and commitments; monitoring progress to meet deadlines; holding others accountable for results; using metrics to manage team performance; assessing impact of KRA outcomes in decision making; emphasizing importance of KRA outcomes.

Be

Collaborative


Managing up other people and groups; reducing anxiety and building alignment; handling of associate suggestions and perspectives; recognizing individual and team accomplishments; rewarding and motivating top performers; partnering with others to improve service; role in cross-functional teams.

Be Safe


Modeling safety behaviors; encouraging error reporting and problem solving, thanking/protecting associates who raise safety concerns; addressing system issues that may lead to patient or associate harm; providing resources to staff to practice safety first; reinforcing staff safety behaviors; addressing unsafe behaviors/choices; participating and partnering with colleagues in site safety initiatives.

BOE Strengths:

Lori is respectful and manages conflict very well. I appreciate her calm demeanor and approach to handling challenging situations. Lori is always prompt in her responses to me and provides me with support when I need it. I enjoy working with Lori



Has been a director for a long time and is knowledgeable about most all processes and resources available.


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2016 Annual Performance Review for LORI S HARPER

Last Name: HARPER First Name: LORI

Title: DIR NURSING SERVICES Department: 25044-1216-CLINICAL ADMINISTRATION

Location: 25044-ADVOCATE BROMENN MEDICAL CNTR Manager: LAURIE M ROUND Division: BROMENN

Originator: OD Admin (OD_Admin) Review Period: 01/01/2015 - 12/31/2015

Due Date: 04/30/2016

Advocate Health Care is committed to the personal and professional development of all associates. This process expresses this commitment by providing a structured approach for leaders to evaluate their performance on goal achievement and behaviors for the designated timeframe.

This review form has four sections: 1) Goal Achievement – evaluation of performance on goals;2) Living Our Values through the Behaviors of Excellence – evaluation of performance on behaviors;3) Overall Summary – explanation of the summary ratings and details on how they are calculated;4) Acknowledgement – electronic signatures from associate and manager.

Please note: When a matrix relationship exists, the Matrix Leader Assessment step will allow multiple matrix leaders to provide comments on the performance form at the same time. If you are in a matrix relationship and this step DOES NOT appear in the route map after the Manager Assessment, the "Get Feedback" option can be used. Through this button, the form can be routed to other managers of the associate to add comments. It is important to remember that when routing this form to another leader, he/she will be able to see the entire review form, including your comments.

Goal information, including results, can be adjusted by clicking the note pad icon in the upper right corner of each goal. However, it is better to make any significant goal edits directly in the goal plan, which will automatically update this review form.

Additionally, comments can be provided to describe any significant achievements and/or obstacles related to the goal. This section accounts for 70% of the overall Calculated Rating.

Category: SAFETY Goal Statement : Achieve a Serious Safety Event Rate reduction of 20% with a stretch of

Key Performance Indicator (KPI) : Weight : Current

Goal Achievement

Introduction

Review Information

Employee Information

Exhibit EP15.B.2 ABMC

5

4.505

Other

Safety Reporting Rate

30% for 2015. (BROMENN) Rating Scales : Scale Range 2 10 3 20 5 30

Rating:

Other Indicators (list here) :

0.0% Results : 47.2

Comments by LORI S HARPER: Nurse LeaderWe far surpassed our goal. MBU was the first high reliability unit. Float pool is scheduled for later this year.

Comments by LAURIE M ROUND: Mother/Baby Unit embraced the safety journey becoming the fist high reliability unit to be trained house-wide. Under Lori's leadership reporting of events, near misses and good catches exceeded target identifying real and potential serious safety events for patients of MBU. Lori has created a culture ready for change and improvement in patient safety and quality of care. The MBU through administrative commitment and direction has created an environment of care that embraces the safety journey to become a high reliability organization to reduce all preventable harm to patients, families, visitors and associates.

Category: SAFETY Goal Statement : Achieve unit BMV Medication scanning rate of 95% with a stretch goal of 98% YTD or average for the last 6 months of the year, whichever is higher. Rating Scales : Scale Range 1 93 2 94 3 95 4 96 5 98

Rating:

Key Performance Indicator (KPI) :


Weight : 5.0%

Current Results : 97.01

Comments by LORI S HARPER: Nurse LeaderSurpassed goal. Comments by LAURIE M ROUND: Results reflective of Lori's leadership and commitment to patient safety.

Category: QUALITY Goal Statement : Achieve a Safety Reporting Rate of 3.5 by year end of 2015. (BROMENN) Rating Scales :


Weight : 0.0%

Current Results : 6.7

Serious Safety Event Rate Change

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3

2.96

Scale Range 1 3.49 3 3.5

Rating:


Comments by LORI S HARPER: Nurse LeaderSurpassed goal. Comments by LAURIE M ROUND: The goal to increase safety reporting while continually decreasing ABMC serious safety events surpassed goal in MBU. This achievement is the result of continuing to identify real or potential threats to patient safety, using the "Be Safe" behaviors and tools and creating a culture that committed to Advocate's Safety Journey. Under Lori's leadership the MBU staff feel empowered to have a questioning attitude stopping the line when needed, asking clarifying questions, paying attention to detail and utilizing peer coaching and checking asking for a double check or encouraging safe behaviors.

Category: QUALITY Goal Statement : Achieve Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2015, based on the 2015 Culture of Safety survey (December Close). (BROMENN) Rating Scales : Scale Range 1 25 2 50 3 75 4 83 5 90

Rating:



Weight : 5.0%

Current Results : 74

Comments by LAURIE M ROUND: ABMC was one percentage point from meeting target but significantly improved from prior years. An area of concern related to staffing was and is currently being addressed through the development of the Nursing Resource Office and float pool, bed meetings at 4AM, 11AM and 4PM to address staffing needs and patient placement under Lori's leadership. This as well as recruitment and retention of nursing talent have been strategic matching appropriate resources with patient care needs.

Category: QUALITY Goal Statement : Achieve a 30 Day Readmissions Ratio of .95 with a stretch goal of .89 for 2015, based on the last reported rolling 6

Key Performance Indicator

(KPI) : Weight : Current

Culture of Safety Survey Percentile

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2.267

3.8

months of data (December Close) or YTD, whichever better. (BROMENN) Rating Scales : Scale Range 1 1.2 2 1.1 3 0.95 4 0.92 5 0.89

Rating:


4.0% Results : 1.06

Category: QUALITY Goal Statement : Achieve an Unassisted Falls Percentile of 80 with a stretch goal of 90 for 2015, based on December 2015 HO Close or YTD, whichever is better. (BROMENN) Rating Scales : Scale Range 1 25 2 50 3 80 4 85 5 90

Rating:



Weight : 5.0%


Comments by LORI S HARPER: Nurse LeaderImplemented new falls interventions for MBU this year.

Comments by LAURIE M ROUND: Exceeded target based on fall prevention strategies and identifying opportunities concurrently as they arise.

Category: QUALITY Goal Statement : Achieve an Infection Control Composite of 100 with a stretch of 150 for 2015, based on December 2015 HO Close. (BROMENN) Rating Scales : Scale Range 1 25

Key Performance Indicator (KPI) : Weight :

5.0% Current Results : 88

2 50 Other Indicators (list here) :

Unassisted Falls Percentile

Readmissions Ratio (30-day)

Infection Control Composite

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2.76

3.56

3 100 4 125 5 150

Rating:

Comments by LORI S HARPER: Nurse LeaderWe continue to struggle with CAUTI. CAUTI team is meeting regularly and will focus on problem areas in 2106. Comments by LAURIE M ROUND: Lori leads the ABMC CAUTI team. Although device days have been significantly reduced house- wide through the work of the CAUTI team and the nurse-driven protocol for removal of Foley's, CAUTI's remain a focus for 2016. With device days dropping the significance of an identified CAUTI has a greater impact on the overall score with the denominator being lower but I need to acknowledge the good performance in the reduction of device days.

Category: QUALITY Goal Statement : Achieve an Inpatient Core Measure Composite of 100 with a stretch goal of 150 for 2015, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better. (BROMENN) Rating Scales : Scale Range 1 25 2 50 3 100 4 125 5 150

Rating:



Weight : 5.0%


Comments by LAURIE M ROUND: ABMC exceeded target in the Inpatient Core Measure Composite Score with each individual metric scoring at or above the 90 percentile.

Category: SERVICE Goal Statement : Achieve a site Patient Engagement - Overall Percentile of the 75th percentile with a stretch goal of the 90th percentile, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better (based on Received Date). (BROMENN) Rating Scales :

Key Performance Indicator (KPI) : Weight : 4.0%


Inpatient Core Measure Composite

Patient Engagement -Overall Percentile

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2.68

3.625

Scale Range 1 25 2 50 3 75 4 83 5 90

Rating:


Category: SERVICE Goal Statement : Achieve a site Patient Engagement - Inpatient HCAHPS Percentile of the 75th percentile with a stretch goal of the 90th percentile, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better (based on Received Date). (BROMENN) Rating Scales : Scale Range 1 25 2 50 3 75 4 83 5 90

Rating:

Key Performance Indicator (KPI) : Patient Engagement -Inpatient HCAHPS Percentile


Weight : 10.0%


Comments by LORI S HARPER: Nurse LeaderInpatient is doing very well and MBU is surpassing expectations.

Comments by LAURIE M ROUND: Under Lori's leadership the inpatient HCAHPS scores for MBU lead the house often scoring in the 90th percentile. MBU was an early adopter of bedside shift report and hourly rounding embracing the patient experience. Lori holds her manager and charge nurses accountable to assure patients and families on the MBU unit consistently apply best practices in to support our Patient and Family Centered Care Model.

Category: SERVICE Goal Statement : Achieve a site Patient Engagement - Outpatient Percentile of the 75th percentile with a stretch goal of the 90th percentile, based on the last reported rolling 6 months of data

Key Performance Indicator (KPI) : Weight : 4.0%

Current Results : 67 Patient Engagement -Outpatient Percentile

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2.68

2.2

(December Close) or YTD, whichever better (based on Received Date). (BROMENN)

Rating Scales : Scale Range 1 25 2 50 3 75 4 83 5 90

Rating:


Category: SERVICE Goal Statement : Achieve a site Patient Engagement - Emergency Department Percentile of the 75th percentile with a stretch goal of the 90th percentile, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better (based on Received Date). (BROMENN) Rating Scales : Scale Range 1 25 2 50 3 75 4 83 5 90

Rating:

Key Performance Indicator (KPI) : Patient Engagement -Emergency Department Percentile


Weight : 4.0%


Category: SERVICE Goal Statement : Achieve a site Physician Engagement Percentile of the 75th percentile with a stretch goal of the 85th percentile, based on the 2015 Physician Engagement survey. (BROMENN) Rating Scales : Scale Range

Key Performance Indicator (KPI) : Weight :

5.0% Current Results : 51 Physician Engagement Percentile

1.4

5

1 45 2 60 3 75 4 80 5 85

Rating:


Comments by LAURIE M ROUND: This is an area of focus house-wide. There were no identified areas of improvement for the MBU. Lori' meets monthly with the Department of OB and the Department of Pediatrics to communicate updates and/or changes in the MBU clinical environment. Lori addresses any physician concerns in a timely manner professionally and with resolution.

Category: SERVICE Goal Statement : Achieve a site Associate Engagement Percentile of the 80th percentile with a stretch goal of the 90th percentile, as measured by the Fall 2015 survey. (BROMENN) Rating Scales : Scale Range 1 50 2 65 3 80 4 85 5 90

Rating:



Weight : 10.0%


Comments by LORI S HARPER: Nurse LeaderExcellent results this year. Comments by LAURIE M ROUND: ABMC exceeded target on associate engagement scores. MBU engagement scores are reflective of Lori's presence on her unit, her communication style with staff, prompt addressing of concerns or needs contribute to the strong engagement scores. L ri is creative in associate recognition and fostering a culture that recognizes others good work. With Nursing Practice Council ori implemented the "caring awards" where associates recognize each other and "paying it forward" to recognize support and ancillary staff.

Category: GROWTH

Goal Statement : Total Deliveries Key Performance Indicator (KPI) : Other

Weight : 10.0%

Current Results : 1,684

Rating Scales :

Associate Engagement Percentile

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5

3.38

Scale Range 1 1,391 2 1,468 3 1,545 4 1,553 5 1,560

Rating:


Comments by LORI S HARPER: Nurse LeaderApproximately 10% growth over 2014. Comments by LAURIE M ROUND: ABMC has 60 percent of the market share in deliveries in our first and secondary market area. The substantial growth in 2015 can be attributed to Lori and her team for ease of physician practice, working with the 24/7 OB physicians and patient and family engagement scores.

Category: FUNDING OUR FUTURE Goal Statement : Achieve a hospital Operating Margin of -5.03% with a stretch goal of -3.78% for YE 2015. Rating Scales : Scale Range 1 -6.53 2 -6.03 3 -5.03 4 -4.53 5 -3.78

Rating:

Key Performance Indicator (KPI) : Other


Weight : 10.0%

Current Results : -4.84

Comments by LAURIE M ROUND: As the representative for BroMenn on the Nursing Finance Committee Lori has lead improvements in productivity through her development of the ursing Resource Office and Float Pool. Labor costs are balanced with matching patient demand and acuity while adjusting to fluctuations in census. The float pool has grown in 2015 from approximately four associates to thirty and continues to grow. Lori leads the way to achieving a flexible competent work force to meet the ever changing demands in patient care.

Category: FUNDING OUR FUTURE Goal Statement : Achieve a Hospital Cost per Discharge of $6548 with a stretch goal of $6417 for YE 2015. Rating Scales : Scale Range


Weight : 5.0%

Current Results : 6,513

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3.538

3.875

1 6,613 2 6,581 3 6,548 4 6,483 5 6,417

Rating:


Comments by LAURIE M ROUND: All of Lori's areas of responsibility demonstrate cost-effective management of supplies and resources to meet or exceed the hospitals goal of Cost per Discharge.

Category: OTHER Goal Statement : Achieve unit RN participation rate of 75% with a stretch goal of 90% in the Spring NDNQI survey. Rating Scales : Scale Range 1 60 2 70 3 75 4 83 5 90

Rating:



Weight : 9.0%


Comments by LAURIE M ROUND: Lori's areas of responsibility as with their associate engagement scores exceeded the identified target of 75 percent participation in the Spring NDNQI Survey.

Advocate has established a common set of behavioral standards that everyone in the organization is expected to model. These Behaviors of Excellence are aligned with our Mission, Values and Philosophy (MVP) and specifically outline how we demonstrate our values in action. Our commitment to these behaviors will help create an Advocate Experience that provides the best place for our patients to heal, physicians to practice and associates to work. For each of the six behaviors, rate the associate’s performance using the radio buttons below. This section accounts for 30% of the Calculated Rating.

PLEASE NOTE: Comments for Associate Strengths and Development Areas on the BoEs are required.

Behaviors of Excellence (BoE) Rating Scale For full descriptions of how to rate each of the Behaviors of Excellence, please Click Here.

Living Our Values through the Behaviors of Excellence

https://advocatehealth.sharepoint.com/sites/Teams/TalentManagementResources/Shared%20Documents/Annual%20Talent%20Review%20Resources/2016%20Leader%20BOE%20Differentiator%20Tool.pdf

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After rating behaviors in the Manager Assessment step, please save the form using the blue disk icon in the top right corner to update the Calculated and Scale Ratings in the Overall Summary section below.

Associate and Manager Ratings

Associate Rating by Official Rating NA 1.0 2.0 3.0 4.0 5.0 NA 1.0 2.0 3.0 4.0 5.0

Be Accountable

Be Collaborative

Be Professional

Be Respectful

Be Responsive

Be Safe

Associate Strengths

Section Comments: Comments by LORI S HARPER: Nurse LeaderMy strengths lie in communication, organization, project management and collaborative relationships. I strive to communicate clearly in each encounter and to look for opportunities to ensure that everyone understands goals and next steps in any project. As the workload increases it is even more important to remain organized and to prioritize appropriately. I love to work on projects and see them as a challenge and an opportunity to learn and to continue to improve my skills. I am proud of the leadership team at BroMenn and in the various system-wide teams that I work with. Relationships are important in order to move forward on our projects and initiatives. Comments by LAURIE M ROUND: I agree with all of Lori's statements. Lori is a high performer at BroMenn but also at the Advocate System Level. Lori excels in project management engaging all key stake holders in the process then effectively plans and executes the project or change. As Advocate moved towards standardization of processes and clinical practices there have been many competing priorities and demands placed on site leadership and Lori has been a role model of transformational leadership, remaining open to new

Behavior of Excellence Feedback

1.0 2.0 3.0 4.0

Exceeds Expectations (Approaches

High)

5.0

Does Not Meet Expectations

(Low)

Approaching Expectations

(Approaches Solid)

Meets Expectations

(Solid)

Significantly Exceeds Expectations

(High)

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ideas, welcoming opportunities for collaboration, and fostering leadership in all roles required of her. Lori has strong relational capacity and builds successful teams that work collaborately towards mutual goals. Lori's strength to provide leadership in overseeing aspects of clinical practice, nursing practice and patient care are at the core of BroMenn's successful 2015 results.

Peer Feedback: BOE Strengths:

I have a great deal of respect for Lori. Lori is a seasoned director, who represents her departments and the hospital well in any interaction. She handles conflict extremely well and always responds with grace when under fire. She is an excellent mentor for nurses wishing to further develop their leadership skills and a champion for nursing as a profession. She is always willing to come to the table for problem-solving and manages others up on a regular basis. She models safety behaviors and the BOEs for others. Lori is respectful and manages conflict very well. I appreciate her calm demeanor and approach to handling challenging situations. Lori is always prompt in her responses to me and provides me with support when I need it. I enjoy working with ri

Peer Job Accountability Strengths:

Appears to represent the hospital in any setting, including system meetings Quickly addresses clinical and quality of care concerns within her areas of responsibility Strong patient advocate Sensitive to the needs of her associates Innovative and resilient Excellent critical-thinking skills

Has been a director for a long time and is knowledgeable about most all processes and resources available.

Associate Development Areas

Section Comments: Comments by LORI S HARPER: Nurse Leader

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This year has been challenging in that there are so many demands on our limited time. My goal is to not become overwhelmed by the number of "things on our plates" and to prioritize and communicate clearly, ensuring that I am working to meet demands as they are needed. Comments by LAURIE M ROUND: Establish priorities for action with the CNE. Establish boundaries when asked to participate or take on a project outside your scope of responsibility. Being viewed as the "go to" person with a "can do" attitude adds to your already "initiative overload."

Peer Feedback: BOE Areas for Learning/Development:

Prioritization is critical given the number of projects and demands on Lori’s plate. She prioritizes well, but at times could communicate more clearly or in a more timely manner with other departments when timelines are being adjusted or deadlines are unable to be met

Three summary ratings are provided in this section: Calculated Rating, Scale Rating, and Overall Rating. The form must be saved to update these summary ratings with any changes made in the sections above. The icon in the top right corner will save the form.

1) The Calculated Rating is computed from the section ratings for Goal Achievement and Living Our Valuesthrough the Behaviors of Excellence.

The Goal Achievement Rating accounts for 70% of the Calculated Rating. It is determined by multiplying each goal's rating by its weight, and then calculating the sum. The Living Our Values through the Behaviors of Excellence Rating accounts for 30% of the Calculated Rating. It is determined by averaging the 6 behavior ratings.

2) The Scale Rating is determined by where the Calculated Rating falls on the scale below:

5 = 4.25 and greater: Significantly Exceeds Expectations 4 = 3.65 - 4.24: Exceeds Expectations 3 = 2.80 - 3.64: Meets Expectations *2 = 2.40 - 2.79: Approaches Expectations*1 = 0.00 - 2.39: Does Not Meet Expectations

* A Performance Deficiency Notice (PDN) should be created for associates rated at this level of performance.Consult Corrective Action Policy 90.013.002 and contact the Human Resources department for assistance in creating a PDN.

3) The Overall Rating is considered the official final rating for this leader’s performance. In most cases, this ratingshould be equal to the Scale Rating. However, the leader responsible for a performance review can assign a higher or lower rating, if appropriate.

Managers must select an Overall Rating using the drop-down box below before sending review form to Associate Signature stage. Please

Overall Summary

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Expectations

note that any deviations from the calculated Scale Rating will be reviewed by Human Resources and must be approved by your manager.

Overall Form Rating: 4.0 - Exceeds

4.0 - Exceeds Scale Rating Expectations

Calculated Rating: 3.9 / 5.0

Rating Weights Goal Achievement 3.57 / 5.0 Achieve a Serious Safety Event Rate reduction of 20% with a stretch of 30% for 2015. (BROMENN) 5 0.0% Achieve unit BMV Medication scanning rate of 95% with a stretch goal of 98% YTD or average for the last 6 months of the year, whichever is higher. 4.505 5.0% Achieve a Safety Reporting Rate of 3.5 by year end of 2015. (BROMENN) 3 0.0% Achieve Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2015, based on the 2015 Culture of Safety survey (December Close). (BROMENN) 2.96 5.0% Achieve a 30 Day Readmissions Ratio of .95 with a stretch goal of .89 for 2015, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better. (BROMENN) Achieve an Unassisted Falls Percentile of 80 with a stretch goal of 90 for 2015, based

2.267 4.0%

on December 2015 HO Close or YTD, whichever is better. (BROMENN) 3.8 5.0% Achieve an Infection Control Composite of 100 with a stretch of 150 for 2015, based on December 2015 HO Close. (BROMENN) 2.76 5.0% Achieve an Inpatient Core Measure Composite of 100 with a stretch goal of 150 for 2015, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better. (BROMENN) Achieve a site Patient Engagement - Overall Percentile of the 75th percentile with a stretch goal of the 90th percentile, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better (based on Received Date). (BROMENN) Achieve a site Patient Engagement - Inpatient HCAHPS Percentile of the 75th percentile with a stretch goal of the 90th percentile, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better (based on Received Date). (BROMENN) Achieve a site Patient Engagement - Outpatient Percentile of the 75th percentile with a stretch goal of the 90th percentile, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better (based on Received Date). (BROMENN) Achieve a site Patient Engagement - Emergency Department Percentile of the 75th percentile with a stretch goal of the 90th percentile, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better (based on Received Date). (BROMENN) Achieve a site Physician Engagement Percentile of the 75th percentile with a stretch goal of the 85th percentile, based on the 2015 Physician Engagement survey. (BROMENN) Achieve a site Associate Engagement Percentile of the 80th percentile with a stretch

3.56 5.0%

2.68 4.0%

3.625 10.0%

2.68 4.0%

2.2 4.0%

1.4 5.0%

goal of the 90th percentile, as measured by the Fall 2015 survey. (BROMENN) 5 10.0%

Total Deliveries 5 10.0% Achieve a hospital Operating Margin of -5.03% with a stretch goal of -3.78% for YE

2015. 3.38 10.0%

Achieve a Hospital Cost per Discharge of $6548 with a stretch goal of $6417 for YE

2015. 3.538 5.0% Achieve unit RN participation rate of 75% with a stretch goal of 90% in the Spring NDNQI survey. 3.875 9.0%

Living Our Values through the Behaviors of Excellence 4.67 / 5.0

Significantly

Be Accountable

Be Collaborative

Be Professional

Be Respectful

Be Responsive

Be Safe

Exceeds Expectations (High)

Significantly Exceeds Expectations (High)


Exceeds Expectations (Exceeds Solid)


Exceeds Expectations (Exceeds Solid)

Optional Overall Summary Comments Comments by LAURIE M ROUND:

With the incredible pressure 2015 has brought facing sweeping changes in health care and the industry Lori remains a steadfast in her loyalty to BroMenn and the Advocate System. This is a mind-set that many struggle with but Lori continues to shine. This is greatly appreciated. Whatever Lori sets out to accomplish it is done with professionalism and ease even in difficult situations she is undaunted and goal focused. It is an honor and pleasure to have Lori as a colleague every day. Both Advocate Health Care, BroMenn and the CNE are privileged to have Lori on our team.

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Please note the associate's and manager's electronic signature reflects receipt and discussion of the Performance Summary. Manager: LAURIE M ROUND 04/28/2016

LAURIE M ROUND Associate: … … … … … . . 04/28/2016

LORI S HARPER

Optional Final Comments Comments by LAURIE M ROUND: It is a pleasure to work with Lori. Lori shares her knowledge and expertise and always keeps me up- to-date on any issues that arise. Lori is a content expert in many areas and can always be counted on to share information, knowledge, and expertise to the CNE for organizational success. Lori is always professional with a calming demeanor even in stressful circumstances or when meeting a tight deadline. Lori's advice as a colleague is pivotal to day-to-day operations and also as a strategic partner. Lori is an authentic leader who remains open to new ideas, welcoming opportunities for collaboration, and fostering leadership among nurses in all roles. It is an honor to work with Lori.

Acknowledgment of Receipt of Performance Summary

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2016 Potential Assessment for:

Employee Information

Last Name:

First Name:

Title:

Department: 25044-1216-CLINICAL ADMINISTRATION

Location: 25044-ADVOCATE BROMENN MEDICAL CNTR

Manager:

Division: BROMENN

Review Information

Originator: OD Admin (OD_Admin)

Review Period: 01/01/2015 - 12/31/2015

Due Date: 04/30/2016

Introduction

Advocate Health Care is committed to the personal and professional development of all associates. This process expresses this commitment by providing a structured approach for leaders to evaluate the potential of their associates.

This form consists of four sections: 1) Advocate Leadership Competencies2) Adaptability3) Desire for More Responsibility4) Overall Summary – explanation of the summary ratings and details on how they are calculated. YouMUST record the Overall Potential Rating by clicking the link to access a pop-up box.

Please note: When a matrix relationship exists, the Matrix Leader Assessment step will allow multiple matrix leaders to provide comments on the potential form at the same time. If you are in a matrix

Exhibit EP15.B.3 Advocate BroMenn Medical Center

relationship and this step DOES NOT appear in the route map after the Manager Assessment, the "Get Feedback" option can be used.Through this button, the form can be routed to other managers of the associate to add comments. It is important to remember that when routing this form to another leader, he/she will be able to see the entire assessment form and you will not have access to make ratings until the form is sent back to you.

Advocate Leadership Competencies

The first four leadership competencies focus on Delivering for Today: Executes for Outcomes, Accelerates Performance, Builds Collaborative Relationships, and Communicates Effectively

The last three leadership competencies focused on Leading for the Future: Leads Change, Acts Strategically, and Builds Talent for the Future.

Indicate the associate’s level of proficiency on each leadership competency using the following scale:

Leadership Competencies Rating Scale

Click Here to access the Leadership Competency Definitions

CR 1.0 2.0 3.0 4.0 5.0

Cannot Rate Limited Basic Proficient Advanced Expert


Please Note: Comments are required.

Expand All Collapse All Official Rating

NA CR 1.0 2.0 3.0 4.0 5.0

Accelerates Performance

Calculated Rating:

Accountability

Engagement

https://advocatehealth.sharepoint.com/sites/Teams/TalentManagementResources/Shared%20Documents/Leadership%20Development/Leadership%20Competency%20Development%20Definitions.pdf

Expectation Setting

Acts Strategically

Calculated Rating:

Action Planning

Enterprise/System Thinking

Strategy Development

Builds Collaborative Relationships

Calculated Rating:

Customer/Stakeholder Focus

Interpersonal Savvy & Influence

Partnership

Builds Talent for the Future

Calculated Rating:

Assessing Talent

Developing Direct Reports

Hiring and Onboarding

Self-Development

Communicates Effectively

Calculated Rating:

Active Listening

Ensuring Effectiveness of Communication

Message Delivery

Executes for Outcomes

Calculated Rating:

Financial Acumen

Process Improvement

Project Management

Results Orientation

Leads Change

Calculated Rating:

Executing Change

Planning for Change

Setting Context for Change

Comments

Comments by:

Adaptability

Indicate the extent to which the individual demonstrates the ability and willingness to learn using the following scale:

Adaptability Rating Scale

CR 1.0 2.0 3.0 4.0 5.0

Cannot Rate

Almost Never

Rarely Regularly Frequently Almost Always

After rating behaviors in the Manager Assessment step, please save the form using the blue disk icon in the top right corner to update Calculated and Scale Ratings in the Overall Summary section below.



NA CR 1.0 2.0 3.0 4.0 5.0

Adaptable/Resilient

Intellectual Curiosity/Drive to Learn

Quick Study

Section Comments:

Comments by LAURIE M ROUND:

Desire for More Responsibility

Indicate the extent to which the individual demonstrates the desire for more responsibility using the following scale:

Desire for More Responsibility Rating Scale

CR 1.0 2.0 3.0 4.0 5.0

Cannot Rate

Almost Never

Rarely Regularly Frequently Almost Always




NA CR 1.0 2.0 3.0 4.0 5.0

Desires Challenge

Shows Commitment to Advocate

Wants More Responsibility

Comments

Comments by:

Overall Summary

Three summary potential ratings are provided in this section: Calculated Rating, Scale Rating, and Overall Rating. The form must be saved to update these summary ratings with any changes made in the

sections above. The icon in the top right corner will save the form.

1) The Calculated Rating is computed from the section ratings for Advocate Leadership Competencies, Desire for More Responsibility and Adaptability. Each of these sections account for one-third (33%) of the Calculated Rating.

2) The Scale Rating is determined by where the Calculated Rating falls on the scale below: 5 = 4.25 – 5.00: High Potential

3 = 2.80 – 4.24: Medium Potential 1 = 0.00 - 2.79: At Potential

The manager must select an overall Potential Rating by clicking the link below before sending the assessment form to the next step. In the pop up window that appears click on the "Add" link next to the "Potential **Mgr View Only" text. This will allow you to add your rating for the most recent assessment period (i.e., last 12 months). Once you have entered the employee's overall Potential Rating (high, medium or at), click the SAVE button and then CLOSE the window.

NOTE: Past assessment ratings may appear in the pop up window. You MUST add and save the rating for the current assessment period (i.e., 1/1/2015 - 12/31/2015) prior to your scheduled calibration meeting.

YOU MUST CLICK THE LINK BELOW TO COMPLETE THIS STEP BEFORE SENDING THE FORM TO CALIBRATION!!!

CLICK HERE to Record Overall Potential Rating

Scale Rating High Potential

Calculated Rating: / 5.0

Rating Weights

Advocate Leadership Competencies 33.34%

Accelerates Performance

Acts Strategically

Builds Collaborative Relationships

Builds Talent for the Future

Communicates Effectively

Executes for Outcomes

Leads Change

Adaptability / 5.0 33.33%

https://performancemanager4.successfactors.com/printpreview?&_s.crb=pb3KysRZpKZ9jUqnSHQ6oR0gdR8%253d#pp_3

https://performancemanager4.successfactors.com/printpreview?&_s.crb=pb3KysRZpKZ9jUqnSHQ6oR0gdR8%253d#pp_3_0








Adaptable/Resilient

Intellectual Curiosity/Drive to Learn

Quick Study

Desire for More Responsibility / 5.0 33.33%

Desires Challenge

Shows Commitment to Advocate

Wants More Responsibility

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