OO10 Evidence of the following documents for nurses at all ... · supervisor notifies the nurse of the approaching appraisal and asks him/her to complete a self-appraisal. The direct

OO10 Advocate BroMenn Medical Center 1

Organizational Overview EXEMPLARY PROFESSIONAL PRACTICE

OO10 – Evidence of the following documents for nurses at all levels (staff nurses up to and including the CNO):

Self-appraisal tools

Peer feedback tools

Performance review tools

Levels of nurses

Self-Appraisal Tool

Peer Feedback Tool Performance Review Tool

Chief Nursing Executive

Combined with Performance

Review

Same tool for CNE, Nurse Leader, Nurse Manager & Charge

Nurse

Combined with Self-Appraisal

Director (nurse leader)


Review


Nurse


Manager (nurse

manager)


Review

Same tool for CNE, Nurse Leader, Nurse Manager, & Charge

Nurse


Charge Nurse (clinical nurse)


Review


Nurse


Advanced Practice

Nurse/Clinical Nurse

Specialist

Same tool used for both self-

appraisal & peer feedback

Same tool used for both self-appraisal &

peer feedback

Separate tool

Nurse Clinician

(clinical nurse)

Separate tool

Separate tool

Separate tool

Evaluation Process Nurses at all levels and roles at Advocate BroMenn Medical Center (ABMC) engage in annual performance reviews that include both a self-appraisal and peer feedback process.


Chief Nursing Executive (CNE), Director, Manager, and Charge Nurse

For nursing leaders, the evaluation 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 m easureable 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. Early each year, the Chief Nursing Executive cascades appropriate goals from her goal plan to each of her nursing directors. The nursing directors then cascade appropriate goals from their goal plans to their nurse managers. Charge nurses are clinical nurses who have day-to-day front-line leadership responsibility. The nurse managers cascade appropriate goals from their goal plans to their charge nurses. The weighting of each goal is established based upon direct supervisor and leader. 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. This feedback is utilized when completing the performance evaluation.

Advanced Practice Nurse (APN)/Clinical Nurse Specialist (CNS) and Nurse Clinician

Direct supervisors receive an automated notice when the APN/CNS and nurse clinician’s performance review due date is approaching. Typically the review date is based on the anniversary of the nurse’s date of hire, but may have been adjusted due to events such as change in position, leave of absence, etc. At that time, the direct


supervisor notifies the nurse of the approaching appraisal and asks him/her to complete a self-appraisal. The direct supervisor also facilitates peer feedback requests to appropriate peers of the nurse and establishes deadlines for completion of the forms. The direct supervisor completes the performance review for the nurse using the feedback provided in the self-appraisal and peer feedback. The review includes an evaluation of the nurse’s performance related to the job accountabilities from the job description and the Behaviors of Excellence. The direct supervisor meets with the nurse to review the appraisal, provide feedback and set goals to enhance competency and encourage professional development for the next year. The review is then submitted electronically.

In 2017, the evaluation will change for all associates across the Advocate Health Care (AHC) system, including APN/CNSs and nurse clinicians. AHC is moving to a goal- based performance review for all associates (similar to the current process for leaders). The intent of the goal-based review is for all associates to be “rowing in the same direction” or working with their peers to achieve organizational goals. Fifty percent of the performance review will be based on successful attainment of the goals and fifty percent will be based on the peer, self and manager review and feedback on the Behaviors of Excellence. The review will be goal-based, therefore a single date for review will be established so all associates 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. For example, in 2016, the system Chief Nursing Executives chose four system-wide goals that are included on the goal plans for all clinical nurses. These four goals are related to: Fall Prevention, Hand Hygiene Compliance, Patient Engagement and Site Composite. The Site Composite is a calculated score based on several core, infection control and financial measures.

In addition to the goals established by the system, each hospital was asked to set two site-specific nursing goals. Nursing leadership at ABMC chose patient education regarding new medications and pain reassessment; two measures that have not yet met the desired goal. Each nursing unit/department was given the option to choose one additional unit specific goal. The goals are established the year prior to the review to allow sufficient time for goal attainment. For example, 2017 goals were established in 2016. Leaders are charged with reviewing goal progress monthly so that all associates are aware of the status/progress.

This new evaluation method includes a self-appraisal and peer feedback process. Nurses will complete their self-appraisal before submitting it electronically to their direct supervisor. There will also be an electronic mechanism to obtain peer feedback. The direct supervisor will incorporate the self-appraisal and peer feedback to complete the performance review.

Self-appraisal tools

o Link to Exhibit OO10.1 Nurse Clinician Self-Appraisalo Link to Exhibit OO10.2 APN/CNS Self-Appraisal & Peer Feedbacko Link to Exhibit OO10.3 Charge Nurse Self-Appraisal & Performance

Review


o Link to Exhibit OO10.4 Manager Self-Appraisal & Performance Review

o Link to Exhibit OO10.5 Director Self-Appraisal & Performance Evaluation

o Link to Exhibit OO10.6 CNE Self-Appraisal & Performance Review

Peer feedback tools

o Link to Exhibit OO10.7 Nurse Clinician Peer Feedbacko Link to Exhibit OO10.2 APN/CNS Self-Appraisal & Peer Feedbacko Link to Exhibit OO10.8 Charge Nurse, Manager, Director & CNE Peer

Feedback

Performance review tools

o Link to Exhibit OO10.9 Nurse Clinician Performance Reviewo Link to Exhibit OO10.10 APN/CNS Performance Reviewo Link to Exhibit OO10.3 Charge Nurse Self-Appraisal & Performance

Reviewo Link to Exhibit OO10.4 Manager Self-Appraisal & Performance Reviewo Link to Exhibit OO10.5 Director Self-Appraisal & Performance Reviewo Link to Exhibit OO10.6 CNE Self-Appraisal & Performance Review

8.16.16 jlm

Exhibit OO10.1 Advocate BroMenn Medical Center

2016 Clinical Nurse Specialist Self/Peer Evaluation for ____ ___________

Return to _____ by__________________________________________

Please evaluate the CNS’s performance on each of the following.

CLINICAL PRACTICE/CONSULTATION: Uses advanced clinical knowledge for provision of specialized care to a patient population. (circle one)

Does not meet expectations Approaching expectations Meets expectations Exceeds expectations Significantly exceeds expectations

Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EDUCATION: Identifies learning needs and provides for programs which will increase staff’s knowledge and improve clinical performance. (circle one)


Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LEADERSHIP: Leads and facilitates team efforts which direct the delivery of patient care and impacts quality, service and cost outcomes per specific patient population. Maintains accountability for professional growth and leadership. (circle one)


Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RESEARCH/QUALITY: Identifies and addresses opportunities to improve clinical practice and delivery of care. (circle one)


Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Behaviors of Excellence

Be Responsive

Timeliness and consideration when addressing communication; attentiveness to issues and concerns;responding with kindness, patience and respect; taking responsibility for issue resolution; adapting tochange, ambiguity and multiple priorities; quality and consistency of service; handling of service feedback

and improvement opportunities. (Circle one)


Be Respectful

Fair and respectful treatment of all people; appreciation for cultural diversity; handling of conflict and difficultconversations; clear and open communication; building candid and trusting relationships; contributing to a

culture of mutual respect; handling of disrespectful behavior. (Circle one)


Be Professional

Maintenance of industry and professional knowledge; application of learning into strategy; response tostressful situations and unexpected challenges; representing Advocate positively; acting in the best interest

of Advocate; demonstrating integrity and ethics; protecting confidentiality and privacy. (Circle one)


Be Accountable

Following through on promises and commitments; monitoring progress to meet deadlines; participation inprocess improvements; contribution to goal achievement; approach to KRA outcomes and achieving results;

role in keeping work area clean, safe and secure. (Circle one)


Be Collaborative

Managing up other people and groups; sharing useful information; effectiveness of handoffs; recognizingindividual and team accomplishments; sharing credit for success; partnering with others to improve service;

participation in cross-functional teams. (Circle one)


Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Top of Form

2015 Annual Performance Review for

Employee Information

Last Name:

First Name:

Title: CHARGE NURSE

Department:

Location: 25044-ADVOCATE BROMENN MEDICAL CNTR

Manager:

Division: BROMENN

Review Information

Originator: OD Admin (OD_Admin)

Review Period: 01/01/2014 - 12/31/2014

Due Date: 04/30/2015

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 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: The "Get Feedback" option is used in situations where a leader has a matrixed relationship with someone other than his/her direct manager. Through this button, the form can be routed to this


other leader 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 Achievement

Goal information, including results, can be adjusted by clicking the Edit Goal 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.

KRA: SAFETY

Goal Statement: Achieve Bedside Medication Scanning rate of 95% with a stretch goal of 98% based on the last month of data or YTD, whichever is better.

Weight: 10.0%

Key Performance Indicator (KPI): Other

Current Results:

Start Date: 01/01/2014

Due Date: 12/31/2014

Rating Scales:

Scale Range

1 90

2 93

3 95

4 97

5 98

Rating:

Comments (Self & Supervisor)

KRA: QUALITY

Goal Statement: Achieve a Unit Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2014, based on the 2014 Culture of Safety survey (December Close).

Weight: 10.0%

Key Performance Indicator (KPI): Culture of Safety Survey Percentile

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 75

4 83

5 90

Rating:


KRA: QUALITY

Goal Statement: Unit fall number of less than 3 with a stretch goal of zero, based on overall number of falls over patient days.

Weight: 10.0%

Key Performance Indicator (KPI): Total Falls Percentile

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 75

4 83

5 90

Rating:


KRA: QUALITY

Goal Statement: Achieve an Infection Control Composite of 100 with a stretch of 150 for 2014, based on December HO Close.

Weight: 10.0%

Key Performance Indicator (KPI): Infection Control Composite

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 100

4 125

5 150

Rating:


KRA: SERVICE

Goal Statement: Achieve a site Unit Associate Engagement Percentile of the 80th percentile with a stretch goal of the 90th percentile, as measured by the Fall 2014 Associate Engagement survey.

Weight: 0.0%

Key Performance Indicator (KPI): Associate Engagement Percentile

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 1

2 65

3 80

4 85

5 90

Rating:


KRA: SERVICE

Goal Statement: Achieve a site Patient Satisfaction - 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).

Weight: 20.0%

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

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 75

4 83

5 90

Rating:


KRA: SERVICE

Goal Statement: Achieve unit participation in the 2014 NDNQI RN Survey of 75% with a stretch goal of 90%.

Weight: 10.0%


Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 75

4 83

5 90

Rating:


KRA: FUNDING OUR FUTURE

Goal Statement: Achieve a Unit Worked Hours per Eqv Patient Day of 14.36 with a stretch goal of 14.22 for year 2014

Weight: 15.0%


Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 15.8

2 15.08

3 14.36

4 14.29

5 14.22

Rating:


KRA: OTHER

Goal Statement: Professional Development Goal: Unit Achieve each of the following by 12/31/14: • Participate on a committee/task force or project (that meets at least 4 times before completion) • Participates on unit shared governance council • Achieves certification in specialty Range: 5 5 (means achieved all of the above activities) 4 4 (means participated in shared governance and achieved certification) 3 3 (means participated in shared governance and committee/task force or project) 2 2 (means participated only in shared governance) 1 1 (means did not achieve any of the above activities)

Weight: 15.0%


Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 1

2 2

3 3

4 4

5 5

Rating:


Living Our Values through the Behaviors of Excellence

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.

1.0 2.0 3.0 4.0 5.0

Does Not Meet Expectations (Low)

Approaching Expectations (Approaches Solid)

Meets Expectations (Solid)

Exceeds Expectations (Approaches High)

Significantly Exceeds Expectations (High)

https://performancemanager4.successfactors.com/doc/advohealth/2014%20BOE%20Differentiator%20Tool.pdf

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

Associate and Manager Ratings

Expand All Collapse All 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

Comments

Summary comments (Self & Supervisor):

Behavior of Excellence Feedback

Associate Strengths

Section Comments:

Comments by

Associate Development Areas

Section Comments:

Comments by

Overall Summary

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 top right will save form.

1) The Calculated Rating is computed from the section ratings for Goal Achievement and Living Our Values through 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 rating should be equal to the Scale Rating. However, the leader responsible for a performance review can assign a higher or lower rating, if appropriate. The Manager must select an Overall Rating using the drop-down box below before sending review form to Associate Signature stage. Please note that any deviations from Scale Rating will be reviewed by HR.

Overall Form Rating:

Scale Rating

Calculated Rating: / 5.0

Rating Weights

Goal Achievement / 5.0

Achieve Bedside Medication Scanning rate of 95% with a stretch goal of 98% based on the last month of data or YTD, whichever is better.

10.0%

Achieve a Unit Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2014, based on the 2014 Culture of Safety survey (December Close).

10.0%

Unit fall number of less than 3 with a stretch goal of zero, based on overall number of falls over patient days.

10.0%

Achieve an Infection Control Composite of 100 with a stretch of 150 for 2014, based on December HO Close.

10.0%

Achieve a site Unit Associate Engagement Percentile of the 80th percentile with a stretch goal of the 90th percentile, as measured by the Fall 2014 Associate Engagement survey.

0.0%

Achieve a site Patient Satisfaction - 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).

20.0%

Achieve unit participation in the 2014 NDNQI RN Survey of 75% with a stretch goal of 90%.

10.0%

Achieve a Unit Worked Hours per Eqv Patient Day of 14.36 with a stretch goal of 14.22 for year 2014

15.0%

Professional Development Goal: Unit Achieve each of the following by 12/31/14: • Participate on a committee/task force or project (that meets at least 4 times before completion) • Participates on unit shared governance council • Achieves certification in specialty Range: 5 5 (means achieved all of the above activities) 4 4 (means participated in shared governance and achieved certification) 3 3 (means participated in shared governance and committee/task force or project) 2 2 (means participated only in shared governance) 1 1 (means did not achieve any of the above activities)

15.0%

https://performancemanager4.successfactors.com/printpreview?&_s.crb=QRFURzZtv%252fkvsYS9g3rAfYGWMFk%253d#pp_3

https://performancemanager4.successfactors.com/printpreview?&_s.crb=QRFURzZtv%252fkvsYS9g3rAfYGWMFk%253d#pp_3_0



























Living Our Values through the Behaviors of Excellence / 5.0

Be Accountable

Be Collaborative

Be Professional

Be Respectful

Be Responsive

Be Safe

Acknowledgment of Receipt of Performance Summary

Please note the associate's and managers electronic signature reflects receipt and discussion of the Performance Summary.

Manager:

Associate:

Bottom of Form










Last Name: First Name:

Title: MGR NURSE 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



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 Achievement

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.


Category: SAFETY

Goal Statement : Achieve a Serious Safety Event Rate reduction of 20% with a stretch of 30% for 2015. (BROMENN)

Key Performance Indicator (KPI) : Serious Safety Event Rate Change

Weight : 5.0%

Current Results : 47.2

Rating Scales : Scale Range 2 10

3 20

5 30

Other Indicators (list here) :

Rating:


Category: SAFETY

Goal Statement : Achieve unit BMV Medication unit scanning rate of 95% with a stretch goal of 98% for the average of YTD or average for the last 6 months of the year, whichever is higher.

Key Performance Indicator (KPI) : Other

Weight : 7.0%



2 94

3 95

4 96

5 98


Rating:

Category: QUALITY

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

Key Performance Indicator (KPI) : Safety Reporting Rate

Weight : 4.0%


Rating Scales : Scale Range 1 3.49

3 3.5


Rating:

Category: QUALITY

Goal Statement : Achieve Length of Stay Days-Medical DRGs of 4.17 with a stretch of 3.83 for 2015, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better. (BROMENN)

Key Performance Indicator (KPI) : Length of Stay Days - Medical DRGs

Weight : 5.0%



2 4.51

3 4.17

4 4

5 3.83


Rating:

Category: QUALITY

Goal Statement : Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2015, based on the 2015 Culture of Safety survey (December Close).

Key Performance Indicator (KPI) : Culture of Safety Survey Percentile

Weight : 5.0%

Current Results : 84


2 50

3 75

4 83

5 90


Rating:

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 months of data (December Close) or YTD, whichever better. (BROMENN)

Key Performance Indicator (KPI) : Readmissions Ratio (30-day)

Weight : 4.0%



2 1.1

3 0.95

4 0.92

5 0.89


Rating:

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.

Key Performance Indicator (KPI) : Unassisted Falls Percentile

Weight : 5.0%



2 50

3 80

4 85

5 90


Rating:

Comments by:

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)

Key Performance Indicator (KPI) : Infection Control Composite

Weight : 4.0%



2 50

3 100

4 125

5 150


Rating:

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)

Key Performance Indicator (KPI) : Inpatient Core Measure Composite

Weight : 5.0%



2 50

3 100

4 125

5 150


Rating:

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)

Key Performance Indicator (KPI) : Patient Engagement -Overall Percentile

Weight : 5.0%



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).

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

Weight : 5.0%



2 50

3 75

4 83

5 90


Rating:

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

Key Performance Indicator (KPI) : Patient Engagement -Outpatient Percentile

Weight : 4.0%



2 50

3 75

4 83

5 90


Rating:

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)

Key Performance Indicator (KPI) : Physician Engagement Percentile

Weight : 5.0%



2 60

3 75

4 80

5 85


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)

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

Weight : 5.0%



2 50

3 75

4 83

5 90


Rating:

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.

Key Performance Indicator (KPI) : Associate Engagement Percentile

Weight : 10.0%



2 65

3 80

4 85

5 90


Rating:

Category: GROWTH

Goal Statement : Achieve Eqv ADC of 20.92 with a stretch goal of 21.10 for YE 2015.


Weight : 2.0%



4 21

3 20.92

2 19.9


1 18.8

Rating:

Category: FUNDING OUR FUTURE

Goal Statement: Achieve an Average Wage Rate of $25.26 with a stretch goal of $25.01 for YE 2015.


Weight : 0.0%



4 25.13

3 25.26

2 26.52

1 27.78


Rating:


Goal Statement : Achieve a productivity index (ADaPT) of 100% with a stretch goal of 105% for year end 2015.

Key Performance Indicator (KPI) : Productivity Index

Weight : 5.0%



2 95

3 100

4 103

5 105


Rating:

Category: OTHER

Goal Statement : Associate Professional Practice: Achieve at least 80% monthly associate attendance per unit at Nursing Practice Council, 1 new professional certification and 1 new STEPS promotion by the end of year 2015. Score 1 if not meeting any of the above Score 2 if only 1 cert or STEPS Score 3 for meeting the above criteria Score 4 for an additional cert or STEPS Score 5 for 2 additional cert or STEPS


Weight : 10.0%

Current Results : 3



2 2

3 3

4 4

5 5

Rating:

Comments by:

Category: OTHER

Goal Statement : Achieve unit RN participation rate of 75% with a stretch goal of 90% in the Spring NDNQI survey for eligible associates.


Weight : 5.0%



2 70

3 75

4 83

5 90


Rating:

Living Our Values through the Behaviors of Excellence 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.

1.0 2.0 3.0 4.0 5.0

Does Not Meet Expectations

(Low)

Approaching Expectations

(Approaches Solid)

Meets Expectations

(Solid)

Exceeds Expectations

(Approaches High)

Significantly Exceeds Expectations

(High)

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 Rating by THERESA L BAILEY 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 Comments by: Associate Development Areas

Section Comments: Comments by:

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

Comments by:

Overall Summary


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




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 rating should 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 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: Scale Rating


Rating Weights Goal Achievement / 5.0

Achieve a Serious Safety Event Rate reduction of 20% with a stretch of 30% for 2015. (BROMENN)

5.0%

Achieve unit BMV Medication unit scanning rate of 95% with a stretch goal of 98% for the average of YTD or average for the last 6 months of the year, whichever is higher.

7.0%

Achieve a Safety Reporting Rate of 3.5 by year end of 2015. (BROMENN)

4.0%

Achieve Length of Stay Days-Medical DRGs of 4.17 with a stretch of 3.83 for 2015, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better. (BROMENN)

5.0%

Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2015, based on the 2015 Culture of Safety survey (December Close).

5.0%

https://performancemanager4.successfactors.com/printpreview?&_s.crb=zK0Cxa5Kk6mOhH%252bveei9U2QOZAo%253d#pp_3

https://performancemanager4.successfactors.com/printpreview?&_s.crb=zK0Cxa5Kk6mOhH%252bveei9U2QOZAo%253d#pp_3_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)

4.0%

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.

5.0%

Achieve an Infection Control Composite of 100 with a stretch of 150 for 2015, based on December 2015 HO Close. (BROMENN)

4.0%

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)

5.0%

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)

5.0%

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).

5.0%

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). (Outpatient Infusion)

4.0%

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)

5.0%

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)

5.0%

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.

10.0%

Achieve Eqv ADC of 20.92 with a stretch goal of 21.10 for YE 2015. 2.0%

Achieve an Average Wage Rate of $25.26 with a stretch goal of $25.01 for YE 2015.

0.0%

Achieve a productivity index (ADaPT) of 100% with a stretch goal of 105% for year end 2015. (

5.0%

Associate Professional Practice: Achieve at least 80% monthly associate attendance per unit at Nursing Practice Council, 1 new professional certification and 1 new STEPS promotion by the end of year 2015. Score 1 if not meeting any of the above Score 2 if only 1 cert or STEPS Score 3 for meeting the above criteria Score 4 for an additional cert or STEPS Score 5 for 2 additional cert or STEPS

10.0%

Achieve unit RN participation rate of 75% with a stretch goal of 90% in the Spring NDNQI survey for eligible associates.

5.0%


Be Accountable Rating

Be Collaborative Rating

Be Professional Rating

Be Respectful Rating

Be Responsive Rating

Be Safe Rating

Acknowledgment of Receipt of Performance Summary Please note the associate's and manager's electronic signature reflects receipt and discussion of the Performance Summary.

Manager:












































Associate:

Exhibit OO10.5 Advocate BroMenn Medical Center2016 Annual Performance Review for

Employee Information Last Name: First Name:

Title: Department: 25044-1216-CLINICAL ADMINISTRATION

Location: 25044-ADVOCATE BROMENN MEDICAL CNTR Manager: LAURIE M ROUND 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 their performance on goal achievement and behaviors for the designated timeframe.



Goal Achievement 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.


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

Key Performance Indicator (KPI) : Weight : Current

Nursing Director

Other

Safety Reporting Rate

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

Rating:


0.0% Results :

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 :

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 :

Serious Safety Event Rate Change

Scale Range 1 3.49 3 3.5

Rating:


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 :

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

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 :

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%

Current Results :

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 :

2 50 Other Indicators (list here) :

Unassisted Falls Percentile

Readmissions Ratio (30-day)

Infection Control Composite

3 100 4 125 5 150

Rating:

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:

Key Performance Indicator (KPI)


Weight : 5.0%

Current Results :

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 :


4.0%

Current Results :

: Inpatient Core Measure Composite

Patient Engagement -Overall Percentile

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:



Weight : 10.0%

Current Results :

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 :

Patient Engagement -Inpatient HCAHPS Percentile

Patient Engagement -Outpatient Percentile

(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 Key Performance Indicator (KPI) :

Weight : Current 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:


4.0% Results :

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


5.0%

Current Results :

Patient Engagement -Emergency Department Percentile

Physician Engagement Percentile

1 45 2 60 3 75 4 80 5 85

Rating:


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%

Current Results :

Category: GROWTH

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

Weight : 10.0%

Current Results :

Rating Scales :

(KPI) : Associate Engagement Percentile

Other

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

Rating:


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:



Weight : 10.0%

Current Results :

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 :

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

Rating:


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%

Current Results :

Living Our Values through the Behaviors of Excellence 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.



Associate Strengths



Associate Rating 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

Section Comments:


Be Safe

Be Responsive

Be Respectful

Be Professional

Be Collaborative

1.0 2.0 3.0 4.0

Exceeds Expectations (Approaches

High)

5.0


(Low)


(Approaches Solid)

Meets Expectations

(Solid)


(High)

Peer Feedback: BOE Strengths:

Peer Job Accountability Strengths:


Section Comments: Comments by

Peer Feedback: BOE Areas for Learning/Development:

Overall Summary 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.


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 rating should 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

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


Scale Rating


Rating Weights

Goal Achievement Achieve a Serious Safety Event Rate reduction of 20% with a stretch of 30% for 2015. (BROMENN) 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. 5.0% Achieve a Safety Reporting Rate of 3.5 by year end of 2015. (BROMENN) 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) 5.0%


Achieve an Unassisted Falls Percentile of 80 with a stretch goal of 90 for 2015, based

4.0%

on December 2015 HO Close or YTD, whichever is better. (BROMENN) 5.0% Achieve an Infection Control Composite of 100 with a stretch of 150 for 2015, based on December 2015 HO Close. (BROMENN) 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

5.0% 4.0%

10.0%

4.0%

4.0%

5.0%

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

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

2015. 10.0%

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

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


Be Accountable Be Collaborative Be Professional Be Respectful Be Responsive

Optional Overall Summary Comments

Please note the associate's and manager's electronic signature reflects receipt and discussion of the Performance Summary. Manager:

Associate:

Optional Final Comments




Last Name:

First Name:

Title: VP PATIENT SVCS/CNE

Department: 25044-1010-ADMINISTRATION


Manager:

Division: BROMENN

Review Information


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 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 Achievement

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

30% for 2015. (BROMENN)


(KPI) : Serious Safety Event

Rate Change

Weight :

0.0%

Current

Results : 47.2

Rating Scales :

Scale Range

2 10

3 20

5 30


Rating:

Category: QUALITY

Goal Statement : Achieve a Safety Reporting

Rate of 3.5 by year end of 2015. (BROMENN)


(KPI) : Safety Reporting Rate

Weight :

4.0%

Current

Results : 6.1

Rating Scales : Other Indicators (list here) :

Scale Range

1 3.49

3 3.5

Rating:

Category: QUALITY

Goal Statement : Achieve Length of Stay Days

of 3.83 with a stretch of 3.64 for 2015, based

on the last reported rolling 6 months of data

(December Close) or YTD, whichever better.

(EUREKA)


(KPI) : Length of Stay Days

Weight :

1.0%

Current

Results : 3.26

Rating Scales :

Scale Range

1 4.27

2 4.01

3 3.83

4 3.73

5 3.64


Rating:

Category: QUALITY

Goal Statement : Culture of Safety Survey

Percentile of 75 with a stretch of 90 for 2015,

based on the 2015 Culture of Safety survey

(December Close). (EUREKA)


(KPI) : Culture of Safety Survey

Percentile

Weight :

1.0%

Current

Results : 89

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: QUALITY

Goal Statement : Achieve a QHi Hospital

Associated Infection Rate of 9% with a stretch

goal of 0% for 2015, based on the last

reported rolling 6 months of data (December

Close) or YTD, whichever better. (EUREKA)


(KPI) : QHi Hospital Associated

Infection Rate

Weight :

1.0%

Current

Results : 8

Rating Scales :

Scale Range

1 27


2 18

3 9

4 5

5 0

Rating:

Category: QUALITY

Goal Statement : Achieve a VTE Prophylaxis

Core Measure of 98.23% with a stretch goal of

99.56% for 2015, based on the last reported

rolling 6 months of data (December Close) or

YTD, whichever better. (EUREKA)


(KPI) : VTE Prophylaxis Core

Measure

Weight :

1.0%

Current

Results : 95.8

Rating Scales :

Scale Range

1 92.39

2 97.44

5 100


Rating:

Category: QUALITY

Goal Statement : Achieve an ED 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. (EUREKA)


(KPI) : ED Core Measure

Composite

Weight :

1.0%

Current

Results : 107

Rating Scales :

Scale Range

1 25

2 50

3 100

4 125

5 150


Rating:

Category: QUALITY

Goal Statement : TO BE FINALIZED: Achieve an

ICU Ventilator Days Index of .85 with a stretch

of 0.74 for 2015, based on December HO

Close or YTD, whichever is better. (BROMENN)


(KPI) : ICU Ventilator Days

Index

Weight :

0.0%

Current

Results : 0.73

Rating Scales :

Scale Range

1 1.1


2 0.99

3 0.85

4 0.8

5 0.74

Rating:

Category: QUALITY

Goal Statement : Achieve a AHRQ PSI

Composite of 3 with a stretch of 5 for YE 2015.

(BROMENN)


(KPI) : AHRQ PSI Composite

Weight :

2.0%

Current

Results : 3

Rating Scales :

Scale Range

1 1

2 2

3 3

4 4

5 5


Rating:

Category: QUALITY

Goal Statement : Achieve Length of Stay Days-

Medical DRGs of 4.17 with a stretch of 3.83



whichever better. (BROMENN)


(KPI) : Length of Stay Days -

Medical DRGs

Weight :

2.0%

Current

Results : 3.79

Rating Scales :

Scale Range

1 4.86

2 4.51

3 4.17

4 4

5 3.83


Rating:

Category: QUALITY


Surgical DRGs of 3.61 with a stretch of 3.4 for

2015, based on the last reported rolling 6





Surgical DRGs

Weight :

2.0%

Current

Results : 3.27

Rating Scales :

Scale Range

1 4.13


2 3.82

3 3.61

4 3.51

5 3.4

Rating:

Category: QUALITY




(December Close). (BROMENN)



Percentile

Weight :

2.0%

Current

Results : 74

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

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


YTD, whichever better. (BROMENN)


(KPI) : Readmissions Ratio (30-

day)

Weight :

2.0%

Current

Results : 1.05

Rating Scales :

Scale Range

1 1.2

2 1.1

3 0.95

4 0.92

5 0.89


Rating:

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)


(KPI) : Unassisted Falls

Percentile

Weight :

2.0%

Current

Results : 84

Rating Scales :

Scale Range Other Indicators (list here) :

1 25

2 50

3 80

4 85

5 90

Rating:

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)


(KPI) : Infection Control

Composite

Weight :

2.0%

Current

Results : 88

Rating Scales :

Scale Range

1 25

2 50

3 100

4 125

5 150


Rating:

Category: QUALITY

Goal Statement : Achieve a PHO Clinical

Integration Score of 80 with a stretch goal of

90 for 2015, based on the last reported

quarter of data (December Close).


(KPI) : PHO Clinical Integration

Score

Weight :

2.0%

Current

Results : 95

Rating Scales :

Scale Range

1 70

2 75

3 80

4 85

5 90


Rating:

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




(KPI) : Inpatient Core Measure

Composite

Weight :

2.0%

Current

Results : 114


Scale Range

1 25

2 50

3 100

4 125

5 150

Rating:

Category: SERVICE

Goal Statement : Achieve a Patient

Engagement - Overall Percentile of the 75th

percentile with a stretch goal of the 90th

percentile, based on the last reported rolling 6


whichever better (based on Received Date).

(EUREKA)


(KPI) : Patient Engagement -

Overall Percentile

Weight :

0.0%

Current

Results : 78

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE

Goal Statement : Achieve a Physician

Engagement Percentile of the 75th percentile

with a stretch goal of the 85th percentile,

based on the 2015 Physician Engagement

survey. (EUREKA)


(KPI) : Physician Engagement

Percentile

Weight :

1.0%

Current

Results : 96

Rating Scales :

Scale Range

1 45

2 60

3 75

4 80

5 85


Rating:

Category: SERVICE

Goal Statement : Achieve a site Patient

Engagement - Inpatient Percentile of the 75th





(EUREKA)



Inpatient Percentile

Weight :

1.0%

Current

Results : 80

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE


Engagement - Outpatient Percentile of the

75th percentile with a stretch goal of the 90th




(EUREKA)



Outpatient Percentile

Weight :

1.0%

Current

Results : 83

Rating Scales :


1 25

2 50

3 75

4 83

5 90

Rating:

Category: SERVICE


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). (EUREKA)


Patient Engagement -

Emergency Department Percentile

Weight :

1.0%

Current

Results : 71

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE







(BROMENN)



Overall Percentile

Weight :

0.0%

Current

Results : 67

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE


Engagement - Inpatient HCAHPS Percentile of

the 75th percentile with a stretch goal of the

90th percentile, based on the last reported


YTD, whichever better (based on Received

Date). (BROMENN)



Inpatient HCAHPS Percentile

Weight :

7.0%

Current

Results : 80

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE







(BROMENN)




Weight :

7.0%

Current

Results : 67

Rating Scales :


1 25

2 50

3 75

4 83

5 90

Rating:

Category: SERVICE







(based on Received Date). (BROMENN)




Weight :

7.0%

Current

Results : 55

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE

Goal Statement : Achieve a site Physician




survey. (BROMENN)



Percentile

Weight :

5.0%

Current

Results : 51

Rating Scales :

Scale Range

1 45

2 60

3 75

4 80

5 85


Rating:

Category: SERVICE

Goal Statement : Achieve an Associate


(75% favorable) with a stretch goal of the

90th percentile (79% favorable), as measured

by the 2015 Associate Engagement

Survey. (Eureka)


(KPI) : Associate Engagement

Percentile

Weight :

1.0%

Current

Results : 79

Rating Scales :

Scale Range

1 65

2 70

3 75

4 77

5 79


Rating:

Category: SERVICE





by the 2015 Associate Engagement Survey.

(BROMENN)



Percentile

Weight :

5.0%

Current

Results : 80

Rating Scales :

Scale Range

1 65

2 70

3 75

4 77

5 79


Rating:

Category: GROWTH

Goal Statement : Achieve a system Growth in

Net Revenue of 100.00% of budget with a

stretch goal of 103.52% for YE 2015. (EUREKA)


(KPI) : Growth in Net Revenue

Weight :

1.0%

Current

Results : 98.14

Rating Scales :

Scale Range

1 96.22

2 98.15

3 100

4 100.79

5 103.52


Rating:

Category: GROWTH

Goal Statement : Achieve a Growth in Net

Revenue of 100% of budget with a stretch

goal of 103.52% for YE 2015. (BROMENN)



Weight :

5.0%

Current

Results :

100.29

Rating Scales :

Scale Range

1 96.22

2 98.15

3 100

4 101.79

5 103.52


Rating:


Goal Statement : Achieve an Operating

Margin of -2.7% with a stretch goal of -1.45%

for YE 2015. (EUREKA)


(KPI) : Operating Margin

Weight :

2.0%

Current

Results : 0.46

Rating Scales :

Scale Range

1 -4.2

2 -3.7

3 -2.7

4 -2.2

5 -1.45


Rating:




for YE 2015. (BROMENN)



Weight :

15.0%

Current

Results : -4.84

Rating Scales :

Scale Range

1 -6.53

2 -6.03

3 -5.03

4 -4.53

5 -3.78


Rating:


Goal Statement : Achieve a site Philanthropy

total of $2 milllion with a stretch of $2.2

million for YE 2015. (BROMENN)


(KPI) : Philanthropy (Millions)

Weight :

4.0%

Current

Results : 5.05

Rating Scales :

Scale Range

1 1.7

2 1.8

3 2

4 2.1

5 2.2


Rating:


Goal Statement : Achieve a Hospital Cost per

Discharge of $6,548 with a stretch goal of

$6,417 for YE 2015. (BROMENN)


(KPI) : Hospital Cost per

Discharge

Weight :

5.0%

Current

Results : 6,513

Rating Scales :

Scale Range

1 6,613

2 6,581

3 6,548

4 6,483

5 6,417


Rating:

Category: COORDINATED CARE

Goal Statement : Achieve a site AdvocateCare

Index score of 100 with a stretch goal of 135



(KPI) : AdvocateCare Index

Weight :

5.0%

Current

Results : 99

Rating Scales :

Scale Range

1 25

2 50

3 100

4 117.5

5 135


Rating:

Category: OTHER

Goal Statement : Staff representaion at

Nursing Practice Council


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 2

2 4

3 8

4 10

5 12


Rating:

Category: OTHER

Goal Statement : Unit RN participation in

Spring NDNQI survey for eligible associates


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 66

2 74

3 82

4 90

5 98


Rating:

Category: OTHER

Goal Statement : Clinical Nurse Manager

achieves professional certification


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 3

2 2

3 1


Rating:

Category: OTHER

Goal Statement : BMV Medication unit

scanning rate


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 93

2 94

3 95


4 96

5 98

Rating:

Category: OTHER

Goal Statement : Associate unit participation

in the AHRQ Culture of Safety Survey

measured as a percent.


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 66

2 74

3 82

4 90

5 98


Rating:

Category: OTHER

Goal Statement : By 12/31/15, achieve two

new Clin III promotion and one new

professional certification.


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 1

2 2

3 3

4 4

5 5


Rating:


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.


Behaviors of Excellence (BoE) Rating Scale

For full descriptions of how to rate each of the Behaviors of Excellence, please Click Here.

1.0 2.0 3.0 4.0 5.0

Does Not Meet

Expectations

(Low)

Approaching

Expectations

(Approaches Solid)

Meets

Expectations

(Solid)

Exceeds

Expectations

(Approaches

High)

Significantly Exceeds

Expectations

(High)

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.


Expand All Collapse All Associate Rating by LAURIE M ROUND 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

Comments by


Section Comments:

Comments by:

Comments by:

Overall Summary

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


1) The Calculated Rating is computed from the section ratings for Goal Achievement and Living Our

Values through 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.


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 rating should 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 note that any deviations from the calculated Scale Rating will be

reviewed by Human Resources and must be approved by your manager.


Scale Rating


Rating Weights


Achieve a Serious Safety Event Rate reduction of 20% with a stretch of


0.0%

Achieve a Safety Reporting Rate of 3.5 by year end of 2015.

(BROMENN)

4.0%

Achieve Length of Stay Days of 3.83 with a stretch of 3.64 for 2015,

based on the last reported rolling 6 months of data (December Close)

or YTD, whichever better. (EUREKA)

1.0%

Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2015,

based on the 2015 Culture of Safety survey (December Close).

(EUREKA)

1.0%

Achieve a QHi Hospital Associated Infection Rate of 9% with a stretch

goal of 0% for 2015, based on the last reported rolling 6 months of

data (December Close) or YTD, whichever better. (EUREKA)

1.0%

Achieve a VTE Prophylaxis Core Measure of 98.23% with a stretch goal

of 99.56% for 2015, based on the last reported rolling 6 months of


1.0%

Achieve an ED 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. (EUREKA)

1.0%

https://performancemanager4.successfactors.com/printpreview?&_s.crb=NYE59UqUPZK1UQhpZZjIB3bfZXc%253d#pp_3

https://performancemanager4.successfactors.com/printpreview?&_s.crb=NYE59UqUPZK1UQhpZZjIB3bfZXc%253d#pp_3_0



















TO BE FINALIZED: Achieve an ICU Ventilator Days Index of .85 with a

stretch of 0.74 for 2015, based on December HO Close or YTD,

whichever is better. (BROMENN)

0.0%

Achieve a AHRQ PSI Composite of 3 with a stretch of 5 for YE 2015.

(BROMENN)

2.0%

Achieve Length of Stay Days-Medical DRGs of 4.17 with a stretch of

3.83 for 2015, based on the last reported rolling 6 months of data

(December Close) or YTD, whichever better. (BROMENN)

2.0%

Achieve Length of Stay Days-Surgical DRGs of 3.61 with a stretch of



2.0%



(BROMENN)

2.0%

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


2.0%

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)

2.0%

Achieve an Infection Control Composite of 100 with a stretch of 150

for 2015, based on December 2015 HO Close. (BROMENN)

2.0%

Achieve a PHO Clinical Integration Score of 80 with a stretch goal of

90 for 2015, based on the last reported quarter of data (December

Close).

2.0%

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)

2.0%

Achieve a 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). (EUREKA)

0.0%

Achieve a Physician Engagement Percentile of the 75th percentile

with a stretch goal of the 85th percentile, based on the 2015

Physician Engagement survey. (EUREKA)

1.0%




































Achieve a site Patient Engagement - Inpatient Percentile of the 75th




1.0%

Achieve a site Patient Engagement - Outpatient Percentile of the 75th




1.0%

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).

(EUREKA)

1.0%

Achieve a site Patient Engagement - Overall Percentile of the 75th



whichever better (based on Received Date). (BROMENN)

0.0%

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)

7.0%





7.0%





(BROMENN)

7.0%

Achieve a site Physician Engagement Percentile of the 75th percentile


Physician Engagement survey. (BROMENN)

5.0%

Achieve an Associate Engagement Percentile of the 80th percentile

(75% favorable) with a stretch goal of the 90th percentile (79%

favorable), as measured by the 2015 Associate Engagement

Survey. (Eureka)

1.0%








































favorable), as measured by the 2015 Associate Engagement Survey.

(BROMENN)

5.0%

Achieve a system Growth in Net Revenue of 100.00% of budget with a


1.0%

Achieve a Growth in Net Revenue of 100% of budget with a stretch


5.0%

Achieve an Operating Margin of -2.7% with a stretch goal of -1.45%


2.0%



15.0%

Achieve a site Philanthropy total of $2 milllion with a stretch of $2.2


4.0%

Achieve a Hospital Cost per Discharge of $6,548 with a stretch goal of


5.0%

Achieve a site AdvocateCare Index score of 100 with a stretch goal of

135 for YE 2015. (BROMENN)

5.0%

Staff representaion at Nursing Practice Council 0.0%

Unit RN participation in Spring NDNQI survey for eligible associates 0.0%

Clinical Nurse Manager achieves professional certification 0.0%

BMV Medication unit scanning rate 0.0%

Associate unit participation in the AHRQ Culture of Safety Survey


0.0%

By 12/31/15, achieve two new Clin III promotion and one new


0.0%

Living Our Values through the Behaviors of Excellence Rating Summary

Be Accountable

Rating

































Be Responsive

Rating

Be Safe

Rating


Comments by:


Please note the associate's and manager's electronic signature reflects receipt and discussion of the

Performance Summary.

Manager:

Associate:






2016 Clinical Nurse Specialist Self/Peer Evaluation for ____ ___________

Return to _____ by__________________________________________

Please evaluate the CNS’s performance on each of the following.

CLINICAL PRACTICE/CONSULTATION: Uses advanced clinical knowledge for provision of specialized care to a patient population. (circle one)


Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EDUCATION: Identifies learning needs and provides for programs which will increase staff’s knowledge and improve clinical performance. (circle one)


Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LEADERSHIP: Leads and facilitates team efforts which direct the delivery of patient care and impacts quality, service and cost outcomes per specific patient population. Maintains accountability for professional growth and leadership. (circle one)


Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RESEARCH/QUALITY: Identifies and addresses opportunities to improve clinical practice and delivery of care. (circle one)


Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Be Responsive

Timeliness and consideration when addressing communication; attentiveness to issues and concerns;responding with kindness, patience and respect; taking responsibility for issue resolution; adapting tochange, ambiguity and multiple priorities; quality and consistency of service; handling of service feedback

and improvement opportunities. (Circle one)


Be Respectful

Fair and respectful treatment of all people; appreciation for cultural diversity; handling of conflict and difficultconversations; clear and open communication; building candid and trusting relationships; contributing to a

culture of mutual respect; handling of disrespectful behavior. (Circle one)


Be Professional

Maintenance of industry and professional knowledge; application of learning into strategy; response tostressful situations and unexpected challenges; representing Advocate positively; acting in the best interest

of Advocate; demonstrating integrity and ethics; protecting confidentiality and privacy. (Circle one)


Be Accountable

Following through on promises and commitments; monitoring progress to meet deadlines; participation inprocess improvements; contribution to goal achievement; approach to KRA outcomes and achieving results;

role in keeping work area clean, safe and secure. (Circle one)


Be Collaborative

Managing up other people and groups; sharing useful information; effectiveness of handoffs; recognizingindividual and team accomplishments; sharing credit for success; partnering with others to improve service;

participation in cross-functional teams. (Circle one)


Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COWORKER/SELF FEEDBACK FORM: Nursing

Associate Receiving Feedback: Your name (optional):

Send back to: by (date).

Please give the associate 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 associate by his/her leader. 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 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:

BOE Areas for Learning/Development:

Job Accountability Strengths:

Job Accountability Areas for Learning/Development:

Performance Pathways

Online Summary of Associate

Review (Nurse Clinician)for

effective 05/19/2016

in job 2033

submitted by

Accountability: Nurse/Patient Relationship: Develops and maintains a therapeutic

relationship throughout the healthcare continuum (20%)

-Role models adaptive communication styles and techniques based on

individual patient needs.

-Role models behaviors necessary to care for patients with altered physical

and psychosocial needs.

-Role models positive behaviors/interventions to promote involvement of the

challenging patient/family.

-Consistently utilizes and individualized, holistic, and non-judgmental

approach to patient care. Models this for other staff.

Significant outcomes,

achievements, opportunities

for development:

Rating:

Accountability: Assuring/Improving Quality Care: Facilitates the patient and family's right to

receive quality, cost effective care (20%)

-Analyzes challenging situations and intervenes as appropriate to optimize

positive patient outcomes.

-Consistently applies evidence-based findings to problems in practice area.

-Cognizant of applications of tested intervention beyond own area.

-Implements strategies to reduce patient risk and increase patient safety.

-Proactively facilitates compliance with regulatory standards.



for development:

Rating:

Accountability: Patient/Staff Education: Demonstrates a commitment to meeting the learning

needs of patients and families. Utilizes appropriate resources to meet those

needs and achieve positive patient outcomes. Assists in creating an

environment that promotes educational growth opportunities for nursing

Job Accountabilities


peers and colleagues. (20%)

-Identifies learning needs of designated patient population. Works

collaboratively to develop strategies to meet these learning needs.

-Identifies staff learning needs. Develops, implements and evaluates formal

and informal educational plans.

Significant outcomes


for development:

Rating:

Accountability: Nursing Process: Demonstrates the use of nursing process as a problem-

solving model. (20%)

-Utilizes knowledge and experience to anticipate and alter the plan of care as

needed.

-Manages complex patient caseloads.

-Takes a proactive role in coordinating referrals and interdisciplinary

discharge planning for specific patient population.

-Manages multiple priorities that promote positive patient and department

outcomes.

Significant outcomes


for development:

Rating:

Accountability: Leadership/Collaboration/Professional Development: Demonstrates respect

and understanding for peers and other clinical disciplines and participates as

an effective member of the patient care team to formulate an integrated

approach to care. Demonstrates leadership behaviors and is committed to

the development of self and others (20%)

-Participates in departmental activities that improve patient care or

administrative systems.

-Role models problem solving and conflict resolution.

-Initiates professional practice goals to enhance individual, unit, and

department goals.

-Earns a minimum of 15 contact hours per year.



for development:

Rating:

Accountability:



for development:

Rating:

Summary Rating:

Be Responsive:

Be Respectful:

Be Professional:

Be Accountable:

Be Collaborative:

Be Safe:

Significant outcomes and

achievements

Opportunities for

improvements:

Summary Rating:

Overall competence:

Associate's progress toward achieving the plans established at the beginning of this review

period:

Specificperformance/learning goals: Timeframe:

Special projects/challenges/training to promote learning: Timeframe:

Support/resources to be provided by manager:

Learning Plan

Overall Summary


Strengths:

Areas for learning/development:

Other comments:

Coworker Feedback

Performance Pathways Online

Draft Summary of Associate Review

for Clinical Nurse Specialist

Accountability: CLINICAL PRACTICE/CONSULTATION: Uses advanced clinical knowledge

for provision of specialized care to a patient population.

Significant outcomes, .


for development:

Rating:

Accountability: EDUCATION: Identifies learning needs and provides for programs which will

increase staff's knowledge and improve clinical performance.



for development:

Rating:

Accountability: LEADERSHIP: Leads and facilitates team efforts which direct the delivery of

patient care and impacts quality, service and cost outcomes per specific

patient population.

Maintains accountability for professional growth and leadership



for development:

Rating:

Accountability: RESEARCH/QUALITY: Identifies and addresses opportunities to improve

clinical practice and delivery of care.



for development:

Rating:

Summary Rating:

Be Responsive:

Be Respectful:

Be Professional:


Job Accountabilities


Be Accountable:

Be Collaborative:

Be Safe:

Significant outcomes and .

achievements:

Opportunities for .

improvements:

Summary Rating:

Overall competence:

Associate's progress toward achieving the plans established at the beginning of this review

period:

.

Specific performance/learning goals: Timeframe:

.

Special projects/challenges/training to promote learning: Timeframe:

.

Support/resources to be provided by manager:

.

Strengths:

.

Areas for learning/development:

.

Other comments:

.

Coworker Feedback

Learning Plan

Overall Summary

Top of Form



Last Name:

First Name:

Title: CHARGE NURSE

Department:


Manager:

Division: BROMENN

Review Information


Review Period: 01/01/2014 - 12/31/2014

Due Date: 04/30/2015

Introduction



Please note: The "Get Feedback" option is used in situations where a leader has a matrixed relationship with someone other than his/her direct manager. Through this button, the form can be routed to this


other leader 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 Achievement

Goal information, including results, can be adjusted by clicking the Edit Goal 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.


KRA: SAFETY

Goal Statement: Achieve Bedside Medication Scanning rate of 95% with a stretch goal of 98% based on the last month of data or YTD, whichever is better.

Weight: 10.0%


Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 90

2 93

3 95

4 97

5 98

Rating:


KRA: QUALITY

Goal Statement: Achieve a Unit Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2014, based on the 2014 Culture of Safety survey (December Close).

Weight: 10.0%

Key Performance Indicator (KPI): Culture of Safety Survey Percentile

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 75

4 83

5 90

Rating:


KRA: QUALITY

Goal Statement: Unit fall number of less than 3 with a stretch goal of zero,

based on overall number of falls over patient days.

Weight: 10.0%

Key Performance Indicator (KPI): Total Falls Percentile

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 75

4 83

5 90

Rating:


KRA: QUALITY

Goal Statement: Achieve an Infection Control Composite of 100 with a stretch of 150 for 2014, based on December HO Close.

Weight: 10.0%

Key Performance Indicator (KPI): Infection Control Composite

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 100

4 125

5 150

Rating:


KRA: SERVICE

Goal Statement: Achieve a site Unit Associate Engagement Percentile of the 80th percentile with a stretch goal of the 90th percentile, as measured by the Fall 2014 Associate Engagement survey.

Weight: 0.0%

Key Performance Indicator (KPI): Associate Engagement Percentile

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 1

2 65

3 80

4 85

5 90

Rating:


KRA: SERVICE

Goal Statement: Achieve a site Patient Satisfaction - 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).

Weight: 20.0%

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

Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 75

4 83

5 90

Rating:


KRA: SERVICE

Goal Statement: Achieve unit participation in the 2014 NDNQI RN Survey of 75% with a stretch goal of 90%.

Weight: 10.0%


Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 25

2 50

3 75

4 83

5 90

Rating:


KRA: FUNDING OUR FUTURE

Goal Statement: Achieve a Unit Worked Hours per Eqv Patient Day of 14.36 with a stretch goal of 14.22 for year 2014

Weight: 15.0%


Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 15.8

2 15.08

3 14.36

4 14.29

5 14.22

Rating:


KRA: OTHER

Goal Statement: Professional Development Goal: Unit Achieve each of the following by 12/31/14: • Participate on a committee/task force or project (that meets at least 4times before completion) • Participates on unit shared governance council• Achieves certification in specialtyRange: 5 5 (means achieved all of the above activities) 4 4 (means participated in shared governance and achieved certification) 3 3 (means participated in shared governance and committee/task force or project) 2 2 (means participated only in shared governance) 1 1 (means did not achieve any of the above activities)

Weight: 15.0%


Current Results:


Due Date: 12/31/2014

Rating Scales:

Scale Range

1 1

2 2

3 3

4 4

5 5

Rating:



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.

1.0 2.0 3.0 4.0 5.0

Does Not Meet Expectations (Low)

Approaching Expectations (Approaches Solid)

Meets Expectations (Solid)

Exceeds Expectations (Approaches High)

Significantly Exceeds Expectations (High)

https://performancemanager4.successfactors.com/doc/advohealth/2014%20BOE%20Differentiator%20Tool.pdf

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


Expand All Collapse All 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

Comments

Summary comments (Self & Supervisor):


Associate Strengths

Section Comments:

Comments by


Section Comments:

Comments by

Overall Summary


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

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




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 ofperformance. 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 rating should be equal to the Scale Rating. However, the leader responsible for a performance review can assign a higher or lower rating, if appropriate.

The Manager must select an Overall Rating using the drop-down box below before sending review form to Associate Signature stage. Please note that any deviations from Scale Rating will be reviewed by HR.


Scale Rating


Rating Weights


Achieve Bedside Medication Scanning rate of 95% with a stretch goal of 98% based on the last month of data or YTD, whichever is better.

10.0%

Achieve a Unit Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2014, based on the 2014 Culture of Safety survey (December Close).

10.0%

Unit fall number of less than 3 with a stretch goal of zero, based on overall number of falls over patient days.

10.0%

Achieve an Infection Control Composite of 100 with a stretch of 150 for 2014, based on December HO Close.

10.0%

Achieve a site Unit Associate Engagement Percentile of the 80th percentile with a stretch goal of the 90th percentile, as measured by the Fall 2014 Associate Engagement survey.

0.0%

Achieve a site Patient Satisfaction - 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).

20.0%

Achieve unit participation in the 2014 NDNQI RN Survey of 75% with a stretch goal of 90%.

10.0%

Achieve a Unit Worked Hours per Eqv Patient Day of 14.36 with a stretch goal of 14.22 for year 2014

15.0%

Professional Development Goal: Unit Achieve each of the following by 12/31/14: • Participate on a committee/task force or project (that meets at least 4 times before completion) • Participates on unit shared governance council • Achieves certification in specialty Range: 5 5 (means achieved all of the above activities) 4 4 (means participated in shared governance and achieved certification) 3 3 (means participated in shared governance and committee/task force or project) 2 2 (means participated only in shared governance) 1 1 (means did not achieve any of the above activities)

15.0%






























Be Accountable

Be Collaborative

Be Professional

Be Respectful

Be Responsive

Be Safe


Please note the associate's and managers electronic signature reflects receipt and discussion of the Performance Summary.

Manager:

Associate:

Bottom of Form










Last Name: First Name:

Title: MGR NURSE 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




Goal Achievement

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.


Category: SAFETY

Goal Statement : Achieve a Serious Safety Event Rate reduction of 20% with a stretch of 30% for 2015. (BROMENN)

Key Performance Indicator (KPI) : Serious Safety Event Rate Change

Weight : 5.0%



3 20

5 30


Rating:


Category: SAFETY

Goal Statement : Achieve unit BMV Medication unit scanning rate of 95% with a stretch goal of 98% for the average of YTD or average for the last 6 months of the year, whichever is higher.


Weight : 7.0%



2 94

3 95

4 96

5 98


Rating:

Category: QUALITY

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

Key Performance Indicator (KPI) : Safety Reporting Rate

Weight : 4.0%



3 3.5


Rating:

Category: QUALITY

Goal Statement : Achieve Length of Stay Days-Medical DRGs of 4.17 with a stretch of 3.83 for 2015, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better. (BROMENN)

Key Performance Indicator (KPI) : Length of Stay Days - Medical DRGs

Weight : 5.0%



2 4.51

3 4.17

4 4

5 3.83


Rating:

Category: QUALITY

Goal Statement : Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2015, based on the 2015 Culture of Safety survey (December Close).

Key Performance Indicator (KPI) : Culture of Safety Survey Percentile

Weight : 5.0%



2 50

3 75

4 83

5 90


Rating:

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 months of data (December Close) or YTD, whichever better. (BROMENN)

Key Performance Indicator (KPI) : Readmissions Ratio (30-day)

Weight : 4.0%



2 1.1

3 0.95

4 0.92

5 0.89


Rating:

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.

Key Performance Indicator (KPI) : Unassisted Falls Percentile

Weight : 5.0%



2 50

3 80

4 85

5 90


Rating:

Comments by:

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)

Key Performance Indicator (KPI) : Infection Control Composite

Weight : 4.0%



2 50

3 100

4 125

5 150


Rating:

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)

Key Performance Indicator (KPI) : Inpatient Core Measure Composite

Weight : 5.0%



2 50

3 100

4 125

5 150


Rating:

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)

Key Performance Indicator (KPI) : Patient Engagement -Overall Percentile

Weight : 5.0%



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).

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

Weight : 5.0%



2 50

3 75

4 83

5 90


Rating:

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

Key Performance Indicator (KPI) : Patient Engagement -Outpatient Percentile

Weight : 4.0%



2 50

3 75

4 83

5 90


Rating:

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)

Key Performance Indicator (KPI) : Physician Engagement Percentile

Weight : 5.0%



2 60

3 75

4 80

5 85


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)

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

Weight : 5.0%



2 50

3 75

4 83

5 90


Rating:

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.

Key Performance Indicator (KPI) : Associate Engagement Percentile

Weight : 10.0%



2 65

3 80

4 85

5 90


Rating:

Category: GROWTH

Goal Statement : Achieve Eqv ADC of 20.92 with a stretch goal of 21.10 for YE 2015.


Weight : 2.0%



4 21

3 20.92

2 19.9


1 18.8

Rating:


Goal Statement: Achieve an Average Wage Rate of $25.26 with a stretch goal of $25.01 for YE 2015.


Weight : 0.0%



4 25.13

3 25.26

2 26.52

1 27.78


Rating:


Goal Statement : Achieve a productivity index (ADaPT) of 100% with a stretch goal of 105% for year end 2015.

Key Performance Indicator (KPI) : Productivity Index

Weight : 5.0%



2 95

3 100

4 103

5 105


Rating:

Category: OTHER

Goal Statement : Associate Professional Practice: Achieve at least 80% monthly associate attendance per unit at Nursing Practice Council, 1 new professional certification and 1 new STEPS promotion by the end of year 2015. Score 1 if not meeting any of the above Score 2 if only 1 cert or STEPS Score 3 for meeting the above criteria Score 4 for an additional cert or STEPS Score 5 for 2 additional cert or STEPS


Weight : 10.0%

Current Results : 3



2 2

3 3

4 4

5 5

Rating:

Comments by:

Category: OTHER

Goal Statement : Achieve unit RN participation rate of 75% with a stretch goal of 90% in the Spring NDNQI survey for eligible associates.


Weight : 5.0%



2 70

3 75

4 83

5 90


Rating:


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.


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

1.0 2.0 3.0 4.0 5.0


(Low)


(Approaches Solid)

Meets Expectations

(Solid)

Exceeds Expectations

(Approaches High)


(High)



Associate Rating by THERESA L BAILEY 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


Comments by:


Section Comments: Comments by:


Comments by:

Overall Summary



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




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, thisrating should 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 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: Scale Rating


Rating Weights Goal Achievement / 5.0 Achieve a Serious Safety Event Rate reduction of 20% with a stretch of 30% for 2015. (BROMENN)

5.0%

Achieve unit BMV Medication unit scanning rate of 95% with a stretch goal of 98% for the average of YTD or average for the last 6 months of the year, whichever is higher.

7.0%

Achieve a Safety Reporting Rate of 3.5 by year end of 2015. (BROMENN) 4.0%

Achieve Length of Stay Days-Medical DRGs of 4.17 with a stretch of 3.83 for 2015, based on the last reported rolling 6 months of data (December Close) or YTD, whichever better. (BROMENN)

5.0%

Culture of Safety Survey Percentile of 75 with a stretch of 90 for 2015, based on the 2015 Culture of Safety survey (December Close). 5.0%













4.0%

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. 5.0%

Achieve an Infection Control Composite of 100 with a stretch of 150 for 2015, based on December 2015 HO Close. (BROMENN)

4.0%

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)

5.0%

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)

5.0%

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).

5.0%

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). (Outpatient Infusion)

4.0%

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)

5.0%

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)

5.0%

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. 10.0%

Achieve Eqv ADC of 20.92 with a stretch goal of 21.10 for YE 2015. 2.0%

Achieve an Average Wage Rate of $25.26 with a stretch goal of $25.01 for YE 2015. 0.0%

Achieve a productivity index (ADaPT) of 100% with a stretch goal of 105% for year end 2015. ( 5.0%

Associate Professional Practice: Achieve at least 80% monthly associate attendance per unit at Nursing Practice Council, 1 new professional certification and 1 new STEPS promotion by the end of year 2015. Score 1 if not meeting any of the above Score 2 if only 1 cert or STEPS Score 3 for meeting the above criteria Score 4 for an additional cert or STEPS Score 5 for 2 additional cert or STEPS

10.0%

Achieve unit RN participation rate of 75% with a stretch goal of 90% in the Spring NDNQI survey for eligible associates. 5.0%


Be Accountable Rating




Be Responsive Rating

Be Safe Rating


Please note the associate's and manager's electronic signature reflects receipt and discussion of the Performance Summary.

Manager:












































Associate:

Exhibit OO10.5 Advocate BroMenn Medical Center2016 Annual Performance Review for

Employee Information Last Name: First Name:

Title: Department: 25044-1216-CLINICAL ADMINISTRATION

Location: 25044-ADVOCATE BROMENN MEDICAL CNTR Manager: LAURIE M ROUND 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 their performance on goal achievement and behaviors for the designated timeframe.



Goal Achievement 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.


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

Key Performance Indicator (KPI) : Weight : Current

Nursing Director

Other

Safety Reporting Rate

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

Rating:


0.0% Results :

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:



Weight : 5.0%

Current Results :

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 :

Serious Safety Event Rate Change

Scale Range 1 3.49 3 3.5

Rating:


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 :

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


(KPI) : Weight : Current

Culture of Safety Survey Percentile

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 :

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%

Current Results :

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


5.0%

Current Results :

2 50 Other Indicators (list here) :

Unassisted Falls Percentile

Readmissions Ratio (30-day)

Infection Control Composite

3 100 4 125 5 150

Rating:

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:

Key Performance Indicator (KPI)


Weight : 5.0%

Current Results :

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 :


4.0%

Current Results :

: Inpatient Core Measure Composite

Patient Engagement -Overall Percentile

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:



Weight : 10.0%

Current Results :

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 :

Patient Engagement -Inpatient HCAHPS Percentile

Patient Engagement -Outpatient Percentile

(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 Key Performance Indicator (KPI) :

Weight : Current 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:


4.0% Results :

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


5.0%

Current Results :

Patient Engagement -Emergency Department Percentile

Physician Engagement Percentile

1 45 2 60 3 75 4 80 5 85

Rating:


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%

Current Results :

Category: GROWTH

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

Weight : 10.0%

Current Results :

Rating Scales :

(KPI) : Associate Engagement Percentile

Other

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

Rating:


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:



Weight : 10.0%

Current Results :

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 :

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

Rating:


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%

Current Results :

Living Our Values through the Behaviors of Excellence 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.




Associate Strengths



Associate Rating 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

Section Comments:


Be Safe

Be Responsive

Be Respectful

Be Professional

Be Collaborative

1.0 2.0 3.0 4.0

Exceeds Expectations (Approaches

High)

5.0


(Low)


(Approaches Solid)

Meets Expectations

(Solid)


(High)

Peer Feedback: BOE Strengths:

Peer Job Accountability Strengths:



Peer Feedback: BOE Areas for Learning/Development:

Overall Summary 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.


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.


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 rating should 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

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


Scale Rating


Rating Weights

Goal Achievement Achieve a Serious Safety Event Rate reduction of 20% with a stretch of 30% for 2015. (BROMENN) 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. 5.0% Achieve a Safety Reporting Rate of 3.5 by year end of 2015. (BROMENN) 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) 5.0%


Achieve an Unassisted Falls Percentile of 80 with a stretch goal of 90 for 2015, based

4.0%

on December 2015 HO Close or YTD, whichever is better. (BROMENN) 5.0% Achieve an Infection Control Composite of 100 with a stretch of 150 for 2015, based on December 2015 HO Close. (BROMENN) 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

5.0% 4.0%

10.0%

4.0%

4.0%

5.0%

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

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

2015. 10.0%

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

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


Be Accountable Be Collaborative Be Professional Be Respectful Be Responsive


Please note the associate's and manager's electronic signature reflects receipt and discussion of the Performance Summary. Manager:

Associate:

Optional Final Comments




Last Name:

First Name:

Title: VP PATIENT SVCS/CNE

Department: 25044-1010-ADMINISTRATION


Manager:

Division: BROMENN

Review Information


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 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 Achievement

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



(KPI) : Serious Safety Event

Rate Change

Weight :

0.0%

Current

Results : 47.2

Rating Scales :

Scale Range

2 10

3 20

5 30


Rating:

Category: QUALITY

Goal Statement : Achieve a Safety Reporting

Rate of 3.5 by year end of 2015. (BROMENN)


(KPI) : Safety Reporting Rate

Weight :

4.0%

Current

Results : 6.1


Scale Range

1 3.49

3 3.5

Rating:

Category: QUALITY

Goal Statement : Achieve Length of Stay Days

of 3.83 with a stretch of 3.64 for 2015, based

on the last reported rolling 6 months of data

(December Close) or YTD, whichever better.

(EUREKA)


(KPI) : Length of Stay Days

Weight :

1.0%

Current

Results : 3.26

Rating Scales :

Scale Range

1 4.27

2 4.01

3 3.83

4 3.73

5 3.64


Rating:

Category: QUALITY




(December Close). (EUREKA)



Percentile

Weight :

1.0%

Current

Results : 89

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: QUALITY

Goal Statement : Achieve a QHi Hospital

Associated Infection Rate of 9% with a stretch

goal of 0% for 2015, based on the last

reported rolling 6 months of data (December

Close) or YTD, whichever better. (EUREKA)


(KPI) : QHi Hospital Associated

Infection Rate

Weight :

1.0%

Current

Results : 8

Rating Scales :

Scale Range

1 27


2 18

3 9

4 5

5 0

Rating:

Category: QUALITY

Goal Statement : Achieve a VTE Prophylaxis

Core Measure of 98.23% with a stretch goal of

99.56% for 2015, based on the last reported


YTD, whichever better. (EUREKA)


(KPI) : VTE Prophylaxis Core

Measure

Weight :

1.0%

Current

Results : 95.8

Rating Scales :

Scale Range

1 92.39

2 97.44

5 100


Rating:

Category: QUALITY

Goal Statement : Achieve an ED Core Measure

Composite of 100 with a stretch goal of 150



whichever better. (EUREKA)


(KPI) : ED Core Measure

Composite

Weight :

1.0%

Current

Results : 107

Rating Scales :

Scale Range

1 25

2 50

3 100

4 125

5 150


Rating:

Category: QUALITY

Goal Statement : TO BE FINALIZED: Achieve an

ICU Ventilator Days Index of .85 with a stretch

of 0.74 for 2015, based on December HO

Close or YTD, whichever is better. (BROMENN)


(KPI) : ICU Ventilator Days

Index

Weight :

0.0%

Current

Results : 0.73

Rating Scales :

Scale Range

1 1.1


2 0.99

3 0.85

4 0.8

5 0.74

Rating:

Category: QUALITY

Goal Statement : Achieve a AHRQ PSI

Composite of 3 with a stretch of 5 for YE 2015.

(BROMENN)


(KPI) : AHRQ PSI Composite

Weight :

2.0%

Current

Results : 3

Rating Scales :

Scale Range

1 1

2 2

3 3

4 4

5 5


Rating:

Category: QUALITY


Medical DRGs of 4.17 with a stretch of 3.83






Medical DRGs

Weight :

2.0%

Current

Results : 3.79

Rating Scales :

Scale Range

1 4.86

2 4.51

3 4.17

4 4

5 3.83


Rating:

Category: QUALITY


Surgical DRGs of 3.61 with a stretch of 3.4 for

2015, based on the last reported rolling 6





Surgical DRGs

Weight :

2.0%

Current

Results : 3.27

Rating Scales :

Scale Range

1 4.13


2 3.82

3 3.61

4 3.51

5 3.4

Rating:

Category: QUALITY




(December Close). (BROMENN)



Percentile

Weight :

2.0%

Current

Results : 74

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

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




(KPI) : Readmissions Ratio (30-

day)

Weight :

2.0%

Current

Results : 1.05

Rating Scales :

Scale Range

1 1.2

2 1.1

3 0.95

4 0.92

5 0.89


Rating:

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)


(KPI) : Unassisted Falls

Percentile

Weight :

2.0%

Current

Results : 84

Rating Scales :


1 25

2 50

3 80

4 85

5 90

Rating:

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)


(KPI) : Infection Control

Composite

Weight :

2.0%

Current

Results : 88

Rating Scales :

Scale Range

1 25

2 50

3 100

4 125

5 150


Rating:

Category: QUALITY

Goal Statement : Achieve a PHO Clinical

Integration Score of 80 with a stretch goal of

90 for 2015, based on the last reported

quarter of data (December Close).


(KPI) : PHO Clinical Integration

Score

Weight :

2.0%

Current

Results : 95

Rating Scales :

Scale Range

1 70

2 75

3 80

4 85

5 90


Rating:

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




(KPI) : Inpatient Core Measure

Composite

Weight :

2.0%

Current

Results : 114


Scale Range

1 25

2 50

3 100

4 125

5 150

Rating:

Category: SERVICE

Goal Statement : Achieve a Patient






(EUREKA)



Overall Percentile

Weight :

0.0%

Current

Results : 78

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE

Goal Statement : Achieve a Physician




survey. (EUREKA)



Percentile

Weight :

1.0%

Current

Results : 96

Rating Scales :

Scale Range

1 45

2 60

3 75

4 80

5 85


Rating:

Category: SERVICE


Engagement - Inpatient Percentile of the 75th





(EUREKA)



Inpatient Percentile

Weight :

1.0%

Current

Results : 80

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE







(EUREKA)




Weight :

1.0%

Current

Results : 83

Rating Scales :


1 25

2 50

3 75

4 83

5 90

Rating:

Category: SERVICE







(based on Received Date). (EUREKA)




Weight :

1.0%

Current

Results : 71

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE







(BROMENN)



Overall Percentile

Weight :

0.0%

Current

Results : 67

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE


Engagement - Inpatient HCAHPS Percentile of

the 75th percentile with a stretch goal of the

90th percentile, based on the last reported


YTD, whichever better (based on Received

Date). (BROMENN)



Inpatient HCAHPS Percentile

Weight :

7.0%

Current

Results : 80

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE







(BROMENN)




Weight :

7.0%

Current

Results : 67

Rating Scales :


1 25

2 50

3 75

4 83

5 90

Rating:

Category: SERVICE







(based on Received Date). (BROMENN)




Weight :

7.0%

Current

Results : 55

Rating Scales :

Scale Range

1 25

2 50

3 75

4 83

5 90


Rating:

Category: SERVICE

Goal Statement : Achieve a site Physician




survey. (BROMENN)



Percentile

Weight :

5.0%

Current

Results : 51

Rating Scales :

Scale Range

1 45

2 60

3 75

4 80

5 85


Rating:

Category: SERVICE





by the 2015 Associate Engagement

Survey. (Eureka)



Percentile

Weight :

1.0%

Current

Results : 79

Rating Scales :

Scale Range

1 65

2 70

3 75

4 77

5 79


Rating:

Category: SERVICE





by the 2015 Associate Engagement Survey.

(BROMENN)



Percentile

Weight :

5.0%

Current

Results : 80

Rating Scales :

Scale Range

1 65

2 70

3 75

4 77

5 79


Rating:

Category: GROWTH

Goal Statement : Achieve a system Growth in

Net Revenue of 100.00% of budget with a




Weight :

1.0%

Current

Results : 98.14

Rating Scales :

Scale Range

1 96.22

2 98.15

3 100

4 100.79

5 103.52


Rating:

Category: GROWTH

Goal Statement : Achieve a Growth in Net

Revenue of 100% of budget with a stretch




Weight :

5.0%

Current

Results :

100.29

Rating Scales :

Scale Range

1 96.22

2 98.15

3 100

4 101.79

5 103.52


Rating:







Weight :

2.0%

Current

Results : 0.46

Rating Scales :

Scale Range

1 -4.2

2 -3.7

3 -2.7

4 -2.2

5 -1.45


Rating:







Weight :

15.0%

Current

Results : -4.84

Rating Scales :

Scale Range

1 -6.53

2 -6.03

3 -5.03

4 -4.53

5 -3.78


Rating:


Goal Statement : Achieve a site Philanthropy

total of $2 milllion with a stretch of $2.2



(KPI) : Philanthropy (Millions)

Weight :

4.0%

Current

Results : 5.05

Rating Scales :

Scale Range

1 1.7

2 1.8

3 2

4 2.1

5 2.2


Rating:


Goal Statement : Achieve a Hospital Cost per

Discharge of $6,548 with a stretch goal of



(KPI) : Hospital Cost per

Discharge

Weight :

5.0%

Current

Results : 6,513

Rating Scales :

Scale Range

1 6,613

2 6,581

3 6,548

4 6,483

5 6,417


Rating:

Category: COORDINATED CARE

Goal Statement : Achieve a site AdvocateCare

Index score of 100 with a stretch goal of 135



(KPI) : AdvocateCare Index

Weight :

5.0%

Current

Results : 99

Rating Scales :

Scale Range

1 25

2 50

3 100

4 117.5

5 135


Rating:

Category: OTHER

Goal Statement : Staff representaion at

Nursing Practice Council


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 2

2 4

3 8

4 10

5 12


Rating:

Category: OTHER

Goal Statement : Unit RN participation in

Spring NDNQI survey for eligible associates


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 66

2 74

3 82

4 90

5 98


Rating:

Category: OTHER

Goal Statement : Clinical Nurse Manager

achieves professional certification


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 3

2 2

3 1


Rating:

Category: OTHER

Goal Statement : BMV Medication unit

scanning rate


(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 93

2 94

3 95


4 96

5 98

Rating:

Category: OTHER

Goal Statement : Associate unit participation

in the AHRQ Culture of Safety Survey



(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 66

2 74

3 82

4 90

5 98


Rating:

Category: OTHER

Goal Statement : By 12/31/15, achieve two

new Clin III promotion and one new



(KPI) : Other

Weight :

0.0%

Current

Results : 0

Rating Scales :

Scale Range

1 1

2 2

3 3

4 4

5 5


Rating:


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.


Behaviors of Excellence (BoE) Rating Scale

For full descriptions of how to rate each of the Behaviors of Excellence, please Click Here.

1.0 2.0 3.0 4.0 5.0

Does Not Meet

Expectations

(Low)

Approaching

Expectations

(Approaches Solid)

Meets

Expectations

(Solid)

Exceeds

Expectations

(Approaches

High)

Significantly Exceeds

Expectations

(High)

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.


Expand All Collapse All Associate Rating by LAURIE M ROUND 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

Comments by


Section Comments:

Comments by:

Comments by:

Overall Summary

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


1) The Calculated Rating is computed from the section ratings for Goal Achievement and Living Our

Values through 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.


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 rating should 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 note that any deviations from the calculated Scale Rating will be

reviewed by Human Resources and must be approved by your manager.


Scale Rating


Rating Weights


Achieve a Serious Safety Event Rate reduction of 20% with a stretch of


0.0%

Achieve a Safety Reporting Rate of 3.5 by year end of 2015.

(BROMENN)

4.0%

Achieve Length of Stay Days of 3.83 with a stretch of 3.64 for 2015,

based on the last reported rolling 6 months of data (December Close)

or YTD, whichever better. (EUREKA)

1.0%



(EUREKA)

1.0%

Achieve a QHi Hospital Associated Infection Rate of 9% with a stretch

goal of 0% for 2015, based on the last reported rolling 6 months of


1.0%

Achieve a VTE Prophylaxis Core Measure of 98.23% with a stretch goal

of 99.56% for 2015, based on the last reported rolling 6 months of


1.0%

Achieve an ED 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. (EUREKA)

1.0%





















TO BE FINALIZED: Achieve an ICU Ventilator Days Index of .85 with a

stretch of 0.74 for 2015, based on December HO Close or YTD,

whichever is better. (BROMENN)

0.0%

Achieve a AHRQ PSI Composite of 3 with a stretch of 5 for YE 2015.

(BROMENN)

2.0%

Achieve Length of Stay Days-Medical DRGs of 4.17 with a stretch of



2.0%

Achieve Length of Stay Days-Surgical DRGs of 3.61 with a stretch of



2.0%



(BROMENN)

2.0%

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


2.0%

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)

2.0%

Achieve an Infection Control Composite of 100 with a stretch of 150

for 2015, based on December 2015 HO Close. (BROMENN)

2.0%

Achieve a PHO Clinical Integration Score of 80 with a stretch goal of

90 for 2015, based on the last reported quarter of data (December

Close).

2.0%

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)

2.0%

Achieve a Patient Engagement - Overall Percentile of the 75th




0.0%

Achieve a Physician Engagement Percentile of the 75th percentile


Physician Engagement survey. (EUREKA)

1.0%




































Achieve a site Patient Engagement - Inpatient Percentile of the 75th




1.0%





1.0%





(EUREKA)

1.0%

Achieve a site Patient Engagement - Overall Percentile of the 75th




0.0%

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)

7.0%





7.0%





(BROMENN)

7.0%

Achieve a site Physician Engagement Percentile of the 75th percentile


Physician Engagement survey. (BROMENN)

5.0%



favorable), as measured by the 2015 Associate Engagement

Survey. (Eureka)

1.0%








































favorable), as measured by the 2015 Associate Engagement Survey.

(BROMENN)

5.0%

Achieve a system Growth in Net Revenue of 100.00% of budget with a


1.0%

Achieve a Growth in Net Revenue of 100% of budget with a stretch


5.0%



2.0%



15.0%

Achieve a site Philanthropy total of $2 milllion with a stretch of $2.2


4.0%

Achieve a Hospital Cost per Discharge of $6,548 with a stretch goal of


5.0%

Achieve a site AdvocateCare Index score of 100 with a stretch goal of

135 for YE 2015. (BROMENN)

5.0%

Staff representaion at Nursing Practice Council 0.0%

Unit RN participation in Spring NDNQI survey for eligible associates 0.0%

Clinical Nurse Manager achieves professional certification 0.0%

BMV Medication unit scanning rate 0.0%

Associate unit participation in the AHRQ Culture of Safety Survey


0.0%

By 12/31/15, achieve two new Clin III promotion and one new


0.0%

Living Our Values through the Behaviors of Excellence Rating Summary

Be Accountable

Rating

































Be Responsive

Rating

Be Safe

Rating


Comments by:


Please note the associate's and manager's electronic signature reflects receipt and discussion of the

Performance Summary.

Manager:

Associate:



