1.Completed the Annual Mandatory Education Requirements (I.E.: Health Stream)

Department Director Performance Appraisal /

Date Prepared:

Department #:

Name:

Title: Clinical Director / Reports to: Admin PCS/CNO or Admin PCS
Job Code: 100 / Grade:
Patient-Age Populations Served: All / Education: ADN, BSN or BS Health related field, MSN
Experience/Qualifications: BSN highly preferred. Requires knowledge of organization and operation of a patient care unit and knowledge of nursing care techniques and methods generally acquired through three to five years experience as a professional nurse with progressive leadership experience in appropriate specialty area.Current RN licensure with South Carolina Board of Nursing..
Special Skills: Works with patients, families, physicians, and other health care providers as well as members of Nursing and Hospital Management
Other:
- American Heart Association Healthcare provider course with Basic Life Support (BLS) certification required to be initially completed with theCOMPANY Staff Development Office within 30 calendar days of hire date (exceptions to obtain certification from a provider other than theCOMPANY Staff Development Office are approved by Staff development on a case by case basis). BLS Recertification is required every two years.
- ACLS preferred
Physical Requirements:MediumWhile performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; occasionally (activity or condition exists up to 1/3 of the time) to use hands, fingers; and frequently to talk or hear. The employee must exert 20 to 35 pounds of force occasionally, and/or 10 to 15 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
May be exposed to infectious specimens, diseases, and soiled laundry, however, potential for personal harm or injury is limited when proper safety and health precautions are followed.
Position Summary: The Clinical Director directs, coordinates, and has twenty-four hour accountability for the nursing services within a specified division of the hospital. She/he evaluates employee work performance providing personnel counseling and disciplinary action in cooperation with the Head Nurse and the CNO. The Clinical Director’s responsibility includes development and maintenance of an ongoing quality monitoring improvement program. The Clinical Director communicates and collaborates with other department for problems identification and resolution. Through the Clinical Director, nursing activities are coordinated with other departments
Threshold Requirements. (NOTE: Employees will forfeit performance pay by “one-half” should he/she fail to meet the “Threshold Requirements”. Please refer to the Department Director Performance Appraisal User’s Guide for further clarification.)

1.Completed the annual mandatory education requirements (i.e.: Health Stream).

2.Complied with Tuberculosis Surveillance Program

3.Ensured active and current professional licensing and/or certification(s).

Completed all Customer Service classes within (12) months of hire date

Has met/meets all requirements

Has not met/does not meet requirements

I. Department Director Performance Appraisal General Standards

Category / Please refer to the Department Director’s Performance Appraisal User’s Guide prior to scoring any general standard
Key: Exceeded x 2, Met x 1, Not Met = 0 / Value / Exceeded / Met / Not Met

Communication/Leadership 16

1.1.Monthly department meetings are held with minutes / 4
1.2.Ensured appropriate communications were either personally shared with staff /delegated to others to be shared with staff, i.e. HR Policy revisions, Staff Development opportunities, Safety etc. / 4
1.3.Demonstrated conflict resolution and problem solving skills with both staff and peers / 4
1.4.Attended monthly Department Director mandatory meetings, Department Director orientation and new employee lunches / 4

Fiscal Management 16

2.1.Determined appropriate staffing needs and scheduling assignments as determined by Dept. of Operations Managers Report. / 4
2.2.Planned, developed and maintained an appropriate and reasonable departmental budget within acceptable guidelines. / 4
2.3.Complied with Georgetown Hospital System policy guidelines related to time and attendance / 2
2.4.Complied with Georgetown Hospital System guidelines related to capital asset policy / 3
2.5.Per Department of Operations Manager’s Report maintained overtime % within Fiscal Year to Date (FYTD) budget. / 2
2.6.Per Department of Operations Manager’s Report maintained contract labor not to exceed the Fiscal Year to Date (FYTD) budget. (Cannot Be Exceeded) / 1

Performance Improvement and Quality Assessment 12

3.1.Demonstrated the development and annual maintenance of appropriate quality indicators for PI opportunities. / 4
3.2.Integrated, where applicable, outcomes from performance improvement opportunities into departmental activities and/or services. / 4
3.3.Demonstrated acceptable patient/customer/employee satisfaction as evidenced by Avatar Patient/Employee Satisfaction Surveys and/or other quantifiable means / 4

Human Resource Management 11

4.1.Ensured the timely completion and return of all assigned annual performance appraisals to HR. / 2
4.2.Demonstrated appropriate HR policy interpretation regarding identifying, addressing and resolving employee corrective actions. / 2
4.3.Ensured employee performance appraisals are developed and/or revised as needed and the timely notification to HR for position review committee. / 1
4.4.Ensured the timely completion and return to the Human Resources Department of all Employee Change Forms and accompanying letter of “resignation”, if applicable. / 1
4.5.Followed Georgetown Hospital System’s “Hiring Process” procedures in a timely and appropriate manner. (Cannot Be Exceeded) / 1
4.6.Demonstrated acceptable annual turnover rates as determined by employee resignation and termination outcomes. / 2
4.7.Ensured timely completion of all FMLA requirements resulting form either a Medical or Personal Leave of Absence. / 1
4.8.Demonstrated a “team” approach towards the recruitment efforts within own department. / 1

Safety and Regulatory Compliance 13

5.1.Followed all guidelines in practice per CMS, JCAHO, CAP, CLIA etc. and any/all other applicable accrediting agencies including but not limited to state and federal regulatory agencies i.e. OIG, DOJ, DHEC, Title VII, FSLA, FMLA, Federal/State Wage and Hour etc. / 2
5.2.Ensured annual review, maintained, and development of departmental policies and procedures / 2
5.3.Demonstrated knowledge of Georgetown Hospital System’s emergency plan and Fire Safety as demonstrated through drill participation and/or actual events. / 2
5.4.Complied with Georgetown Hospital System’s Workers Compensation Policy to include timeliness of addressing an injury, return to work, employee education and compliance, employee follow up, and corrective action measures regarding program violations along with preventative measures for avoidance in the future. / 2
5.5.Complied with the identification and reporting requirements as outlined within Georgetown Hospital System’s Drug Free Workplace Policy. (Cannot Be Exceeded) / 1
5.6 Demonstrated acceptable worksite injury avoidance as determined by monthly Safety Reports. / 2
5.7 Demonstrated acceptable compliance with Georgetown Hospital System rules and expectations including but not limited to professional image policy, breaks, tobacco usage, parking, ID badges, and infection control practices etc. (Cannot Be Exceeded) / 2

Staff Development and Education and Training 15

6.1.Promoted professional growth of self and staff through coaching, mentoring, developing and challenging staff as well as training for anticipated future staff development needs / 2
6.2.Promoted “Team Work” and Community Involvement” evidenced by having volunteered for committees, initiated task groups/committees/meetings, sought opportunities for professional involvement within Georgetown Hospital System and/or the local community / 3
6.3.Ensured timely completion of all departmental annual mandatory employee education requirements (i.e.Health Stream. (Cannot Be Exceeded) / 3
6.4.Demonstrated personal competency in Windows/Internet Explorer, Microsoft Office Applications, and other key applications impacting the department to further Georgetown Hospital System’s HH&N “Most Wired” information technology status. / 2
6.5.Ensured personal and staff’s compliance with mandatory compliance training, HIPAA Privacy and Security Training, etc. (Cannot Be Exceeded) / 3
6.6.Ensured the completion of general orientation for all new employees (Cannot Be Exceeded) / 2

System Mission/Values 17

7.1.Demonstrated support of organizational change as evidenced through effectiveness of implementation. / 3
7.2.Personally demonstrated ethical and professional behaviors through actions and interactions with employees, other staff, patients, guests and customers. as well as sought the same from own employees / 4
7.3 Embraced the Georgetown Hospital System Customer Service initiatives (TRACC) / 6
7.4 Demonstrated personal compliance and sought same from own employees with the Georgetown Hospital System Corporate Compliance, HIPAA, and Standards of Conduct programs. / 4

Total

/ 100

II Position Specific Standards (100) total points)

Point / Key: Exceeds x 2, Meets x 1, Needs to Improve = 0 / 2 / 1 /

N/a

20 / Standard 8: Promotes and organizes educational opportunities for staff. Encourages staff to achieve certification in their area of practice.
Measurement: Meets standard as evidenced by staff participation in educational opportunities and/or sitting for certification. Exceeds standard when clear evidence exists that the Clinical Director has taken a proactive role in recruiting and supporting staff for these opportunities. Does not meet standard if there is no evidence of activities related to obtaining certification.
20 / Standard 9: Consistently monitors staff/patient ratio and adjusts staffing based on identified care needs of patients. Assists staff in direct care when needed thereby demonstrating teamwork and clinical excellence.
Measurement: Exceeds standard when

95% or > staffing is appropriate
provides direct patient care a minimum of 36 hrs annually

Meets standard as observed by peers and manager in daily activities.

90-95% staffing is appropriate
provides direct patient care a minimum of 24 hours annually

Fails to meet standard when there is no evidence that the Clinical Director takes a hands on approach when required.
20 / Standard 10: Develops a positive rapport and maintains open lines of communication with members of the Medical Staff to ensure quality patient outcomes.
Measurement: Exceeds standard when (0) complaints are received by Administration. Meets the standard when evidence exists or Clinical Director is observed proactively working with members of the Medical Staff to address issues related to providing quality care. Fails to meet this standard when there is evidence of a lack of initiative in working with and communicating with the medical staff.
20 / Standard 11: Supports patient safety by creating an environment that nurtures and assists staff allowing them to focus on patient safety related issues.
Measurement: Standard is met as evidenced by Fall Rates, Smart Lift Program, Hospital Acquired Infection Rates, Pressure Ulcer Rates, and Restraints that are maintained below benchmarks. Standard is exceeded when evidence exists that proactive steps have been undertaken by the unit to improve rates. Fails to meet standard when issues are not addressed
20 / Standard 12: Develops the avenues and opportunities for staff to pursue the journey of excellence through Shared Governance.
Measurement: Meets standards when evidence exists that unit-based councils are functional and staff are scheduled to allow them to attend required meetings. Exceeds the standard by direct involvement as a facilitator or mentor for a hospital-wide council or team. Fails to meet the standard if no evidence exists that the unit is participating in elements of Shared Governance.
100 / Subtotal Points - Section II Position Specific Standards

Total Points- Section II Position Specific Standards

Subtotal Points – Section I Department Director General Standards
Total Points- Department Director General Standards

Grand Total Points – Add Total Column Points from Sections I & II

Performance Improvement Plan/Accomplishments
Employee Comments
Manager’s Comments
I have seen this appraisal in its entirety and its completed form and have had the opportunity to discuss its contents thoroughly with my immediate supervisor.
Date / Date
Employee Signature / Supervisor Signature
GeorgetownHospital System - Employee Acknowledgement of Confidentiality,
Conflict of Interest and Corporate Compliance/Standards of Conduct
______
Employee SignatureDate