UPMC Nursing Peer Review Form
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1 Person Being Reviewed: Return to: Return by: UPMC Nursing Peer Review Form As we strive to achieve the best quality care and outcomes for our patients, we elicit feedback from your peers that is reflective of your performance and needs for professional growth/development. This form has been designed to obtain your feedback regarding your peer s performance. Please be honest and objective in your responses and as specific as possible in your feedback. Your feedback will assist your department head in completing the performance review process. Please rate your peer s behavior for the following period: to by indicating the rating on the 5 point scale below. Your written comments are very important in helping the individual understand why you rated the competency the way that you did Examples of what they do well are as important as what they can improve upon. Providing examples of situations or behaviors that give the individual a clear picture of what they are doing well or not so well will be invaluable to them. If the individual doesn t know what you mean by your rating, comments can clarify and suggest more effective actions. Instructions for Peer Review Process: Department head will distribute 2 Peer Evaluations and Employee being reviewed will distribute 3 Peer Evaluations. Teamwork 1. Does this individual usually offer assistance to others and help without being asked? this this 2. Creates and/or contributes to a positive work environment through attitude and ability to work with others. this this
2 3. This individual is flexible and adapts to changes in the work environment. this this Customer Service 1. In your observation of this employee, does this individual use a caring, sensitive, approach to meet individualized customer needs? this this 2. Utilizes the principles of Relationship Based Care to improve the customer experience. this this 3. Promotes patient advocacy. Perception of customer service is a compassionate and caring experience and includes emotional, spiritual and physical needs. this this
3 Accountability 1. Accepts responsibility for completing assignments and makes appropriate provisions for incomplete tasks. this this 2. This individual is able to manage his or her daily workload. this this 3. Demonstrates skills, sound clinical judgment, and decision-making abilities. this this 4. Shares learned knowledge with others through precepting, mentoring, and by acting as a role model. Transformational Leadership this this 5. Incorporates new technology/innovation into clinical practice. New Knowledge Innovations and Improvements this this
4 Image of Nursing/Professionalism 1. Presents a professional image at all times, including hygiene/personal appearance and wearing hospital ID as per dress code policy. In addition, this individual is professional in his or her verbal and non-verbal communication skills. this this 2. Displays professional skills/behaviors which reflect commitment, collaboration, responsibility, and follow-through. Transformational Leadership this this 3. Adheres to and acts as a role model with regard to personal electronic device guidelines and appropriate computer usage. Structural Empowerment this this Communication 1. Acts as an approachable resource, shares knowledge and experience with patients family members and members of the healthcare team. Structural Empowerment this this
5 2. Discourages gossip and negative talk; helps to resolve conflicts within the team. this this 3. Treats patients, families, visitors, and all members of the healthcare team with dignity and respect. this this Safety/Quality Outcomes 1. Adheres to and promotes hospital safety and regulatory standards. Structural Empowerment this this 2. Maintains and promotes a clean and orderly work environment. this this
6 3. Practice reflects the current evidence and the connection between the patient plan of care and nurse sensitive indicators/core measures, National Patient Safety Goals and positive patient outcomes. New Knowledge Innovations and Improvements this this Optional: 1. What does this individual do well that you appreciate the most? 2. What do you think this individual can improve on or further improve? I have completed this Peer Evaluation to the best of my abilities and without the assistance of others. I have tried to be objective in my assessment of the performance of this associate during this rating period. I know that my comments will be passed on to this associate. Evaluator s Name: Signature: Completing this form and returning electronically via serves as an electronic signature and validates this form.
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