CLINICAL STAFF PERFORMANCE EVALUATION 1 of 5 Review Date: The Performance Evaluation contains items from the job description. Include examples of critical incidents that are representative of the rating in the evaluation. Use the following Rating Codes when filling out the Performance Evaluation. 6 Exceptional: No improvement in performance required. Actions had a significant positive impact on Practice functions. Performance consistently exceeded expected outcomes. 5 Excellent: No improvements in performance required. Actions had a positive impact on Practice functions. Performance consistently met, and occasionally exceeded, expected outcomes. 4 Adequate: No improvements in performance required. Actions had no negative impact on Practice functions. Performance met excepted outcomes. 3 Mediocre: Minor improvements in performance required. Actions had no negative impact on Practice functions. Performance met, and occasionally failed to meet, expected outcomes. 2 Inferior: Minor improvements in performance required. Actions had a negative impact on Practice functions. Performance met, and occasionally failed to meet, expected outcomes. 1 Deficient: Improvements in performance required. Actions had a significant negative impact on Practice functions. Performance consistently failed to meet expected outcomes. Employee's Name: Employee's Job Title: Period Covered (mo/yr to mo/yr): to Reviewer's Name: Reviewer's Job Title:
CLINICAL STAFF PERFORMANCE EVALUATION 2 of 5 JOB SUMMARY: Performs patient care activities. Takes and develops x-ray films. Cleans, packages, sterilizes, and stores supplies, instruments, and equipment. 1. Supports, and performs according to, approved policies and procedures. 2. Supports risk management and participates in programs directed to patient and staff safety. 3. Considers patient rights in performance of job duties and responsibilities. 4. Contributes to the quality management process; identifies role and contributions upon request. 5. Reports observed or suspected violations, hazards, and noncompliance according to 6. Observes safety measures in performance of job duties and responsibilities. 7. Responds to emergency situations with competence and composure. 8. Interactions are respectful and courteous. 9. Objectively evaluates suggestions, grievances, and processes to identify opportunities to improve performance and quality of care or seeks further guidance, as needed. 10. Communicates effectively and professionally using a translator when necessary. 11. Documents that information received from the patient is disseminated to the appropriate people or departments. 12. Accurately assesses and interprets agespecific patient data. 13. Considers age-specific patient requirements when responding to emergency situations. 14. Seeks new learning experiences by accepting challenging opportunities and responsibilities. 15. Objectively evaluates suggestions or criticisms and attempts to improve performance or seeks further guidance as needed.
CLINICAL STAFF PERFORMANCE EVALUATION 3 of 5 16. Attends and actively participates in meetings, committees, inservices, seminars, workshops, conferences, quality management activities according to job responsibilities and Practice requirements. 17. Documents patient care records and other forms according to 18. Communicates information about the patient's status to others responsible for patient care. 19. Accurately comprehends and interprets verbal orders and directions. 20. Performs assigned activities to provide safe and individualized care. 21. Recognizes patient's need for support and provides for privacy and confidentiality. 22. Prepares equipment/supplies needed for care of patients and for performing diagnostic tests. 23. Tests and monitors equipment for proper working condition. 24. Confirms that all persons in the room are properly shielded before activating x-ray. 25. Adheres to principles of aseptic technique in performing duties. 26. Follows manufacturer's specifications and OSHA guidelines when performing x-ray procedures. 27. Handles equipment and instruments correctly to provide availability and safety. 28. Maintains adequate supplies to provide immediate availability during the procedure. 29. Maintains a clean and organized work area. 30. Checks sterilizer indicators for proper functioning. 31. Performs required biological monitoring tests on all sterilizers according to
CLINICAL STAFF PERFORMANCE EVALUATION 4 of 5 32. Cleans sterilizers according to Practice policy. 33. Handles, cares for, and cleans instruments according to Practice policy and manufacturer's recommendations. 34. Verifies that each item is in good working condition; lubricates items when needed and inspects instruments under a microscope for damage and defects. 35. Sorts and arranges items into correct trays and wraps trays and individual items according to Facility policy. 36. Positions items correctly in sterilizer and selects proper cycle; seeks assistance when needed. 37. Accurately labels each item with name and expiration date. 38. Performs weekly inspections of all sterile items in the Practice and checks for outdated items and package integrity of wrapped sterilized items; replaces items as necessary. 39. Places items in correct location. 40. Observes and reports need to replenish or revise supply inventories for the sterile processing area. 41. Maintains and updates the instrument tray inventory list. 42. Maintains current information regarding surgeon s routine preference cards. 43. Accurately documents count of items sent to and returned by the laundry service. 44. Follows housekeeping guidelines for cleaning responsibilities. 45. Monitors contracted housekeeping activities for correct cleaning methods. 46. Reports any damaged equipment discovered during routine cleaning. 47. Handles hazardous waste according to
CLINICAL STAFF PERFORMANCE EVALUATION 5 of 5 48. Uses cleaning agents and equipment according to safety, manufacturer, and Practice standards. 49. Performs preventive maintenance assignments according to manufacturers' directions. 50. Monitors effectiveness of pest control service. SUMMARY RATING Total = Divided by 50 =