PERFORMANCE APPRAISAL

Patient Safety Specialist

Employee Name	Evaluator's Name
Date:	Title:
Clinical Area:	Facility:

For each area of performance evaluate the level of achievement demonstrated during the past year.

LEVEL OF ACHIEVEMENT

5=Outstanding 4=Highly Effective 3=Effective 2=Improvement Needed 1=Unacceptable

or NA= Not Applicable

Areas of Performance	Level of Achievement
A. Autonomy and Accountability
1. Functions within legal framework of the state currently employed.
2. Demonstrates reliability in meeting deadlines and completing responsibilities.
3. Demonstrates responsibility and reliability in meeting scheduled deadlines.
4. Complies with hospital policies and procedures.
5. Displays ability to utilize appropriate channel(s) for communication and/or problem solving.
6. Performs work assignment with minimum need for supervision and guidance.
7. Possesses skills and technical competence to execute work responsibilities.
8. Operates within the established company guidelines
9. Assists with training/education of staff, contributes to an open learning environment.
10. Adheres to Hospital and Company health and safety standards.
B. Professionalism
1. Promotes good public relations for CCMS and the Hospital.
2. Establishes and maintains therapeutic and supportive relationship.
3. Effectively expresses self. Listens attentively and creates a climate of open communication. Respects confidentiality and privacy.
4. Accepts constructive comments from hospital/contracting company as a mechanism for improvement.
5. Functions as an integral part of the health care delivery team and participates in the maintenance of a cohesive work environment.
6. Maintains credentials and education files as per JCAHO standards and Department of Health Regulations.
7. Communicates accurately/appropriately with patients, family and other personnel.
8. Reports to work in a timely manner.

C. Data Collection, Analysis, and Tracking
1. Conducts trend analysis and other statistical computation. Utilizes patient safety analysis techniques (methods) including root cause analysis, cause and effect analysis, and failure mode and effects analysis (FMEA) as applied to the health care setting in the design, analysis and trending of PSP related data.
2. Reviews, analyzes, and trends reports for demonstration of adherence to and compliance with regulatory agency and accreditation standards.
3. Maintains and conducts periodic appraisals of the adequacy of facility wide PSP activities, policies, and procedures to ensure function effectiveness.
Areas of Performance	Level of Achievement
4. Collaborates with Office of Continuous Improvement (OCI) and Risk Management (RM) to ensure that risk reduction strategies and improvement recommendations resulting from root cause analyses are followed up.
5. Reviews all safety-related events to insure that adequate documentation on each case exists.
6. Participates in problem assessment, solution recommendation, implementation, and follow-up on corrective actions.
D. Reports
1. Communicates findings and conclusions of data analysis and trending effectively. Presents data recognizing the different functions, foci, and needs of MTF departments.
E. Root Cause Analysis (RCA)
1. Provides the RCA and action plan to the MTF official(s) with responsibility for the systems or processes involved .
2. Revises, finalizes, tracks and trends the RCA reports and action plans.
3. Utilizes QI tools to assist RCA Teams in the analysis of adverse events and close calls.
F. Briefings, Meetings, and Presentations
1. Prepares briefings on PSP activities for the RM/PI or other designated MTF leaders.
2. Participates in preparation for oversight visits by the internal and external review groups and assures continuing MTF efforts to fulfill JCAHO Patient Safety Standards.
3. Coordinates PSP activities with the designated Patient Safety/ Risk Management Advisory Group through which adverse events and close calls are reviewed.
4. Coordinates presentation of findings by presenting the data in a manner that demonstrates the sequence and timing of key program events and milestones, and methods of evaluating program accomplishments at the MTF.
5. Prepares briefings on PSP activities for the RM/PI or other designated MTF leaders for presentation to appropriate committees, department heads, directorates, and leadership.
G. Training/Instruction
1. Maintains current knowledge in PSP, RM, CI, design, human factors, data analysis, and epidemiology, by attendance at required meetings, review of current literature and educational programs.
2. Develops, coordinates, presents, and teaches ongoing Patient Safety Education in the form of just-in-time training for RCA Teams, one-on-one consultations, and in-service training to clinicians and other medical and administrative staff.
3. Serves as process expert and provide OCI representatives and RCA teams with just-in-time training.
4. Maintains an understanding of relationships with other programs and key administrative support functions within the MTF to include an understanding of the MTF’s supporting parent agencies.
H. General Administration
1. Maintains all necessary files/records as deemed appropriate by internal or external policies and/or by the JAG and ensures maximum protection from discoverability as required by the 10 USC 1102 regulations and the Privacy Act.
2. Maintains confidentiality of information.

Please include GOALS AND COMMENTS on Reverse

Employee: Date:

Clinical Director: Date:

CCMS Manager: Date