UPMC My Nursing Career Senior Professional Staff Nurse Promotional Process and Annual Review Checklist Nurses in this role are expected to have active participation in a manager approved professional contribution that supports the hospital/system s goals. There is a list of suggested areas of focus on the My Professional Contribution form located on the Nursing Infonet. For those new to the Senior Professional Nurse role, submit your nursing portfolio that includes the following: My Professional Contribution Annual Initiation Form Please complete this form completely. You are encouraged to review the My Nursing Career Professional Contribution Feedback Tool used to evaluate your contribution so you are prepared to submit the required information. This document can be found on the nursing infonet. It is also recommended that staff members identify a mentor to provide guidance on projects. Professional RN Yearly Update Form For those continuing in the Senior Profession Nurse role, submit your nursing portfolio that includes the following: My Professional Contribution Annual Outcome Report This form will document your completion of last year s contribution. Please complete thoroughly as it will be used to evaluate the success of your contribution. My Professional Contribution Annual Initiation Form for this upcoming year s contribution. Please complete this form completely. Include update goals, methodology, outcomes and measurements. You are encouraged to review the My Professional Contribution Feedback Tool used to evaluate your contribution so you are prepared to submit the required information. This document can be found on the nursing infonet. It is also recommended that staff members identify a mentor to provide guidance on projects. Professional RN Yearly Update Form Timeline Key Dates If your performance evaluation is due in: Forms should be submitted to your unit director/manager by: January Prior to November 1 February Prior to December 1 March Prior to January 1 April Prior to February 1 May Prior to March 1 June Prior to April 1 July Prior to May 1 August Prior to June 1 September Prior to July 1 October Prior to August 1 November Prior to September 1 December Prior to October 1

My Nursing Career Sr. Professional Staff Nurse Professional Contribution Annual Review Process The Nurse completes work on his/her contribution throughout the year. 6 Month Mid-Year Nurse provides update to Unit Director /Manager on project status. 90 Days Prior to Performance Review Unit Director/Manager or designee provides to Nurse: * Self-assessment * My Professional Contribution Annual Outcome Report to evaluate the current year s contribution * My Professional Contribution Annual Initiation form (for next year s contribution) * Professional RN Yearly Update Form 60 Days Prior to Performance Review Nurse submits these completed forms to Unit Director/Manager or designee : * My Professional Contribution Annual Outcome Report * My Professional Contribution Annual Initiation Form * Professional RN Yearly Update Form Within 4 Weeks after Receipt of Forms My Nursing Career Review Panel meets to oversee process and review forms. The panel will complete the My Nursing Career Professional Contribution Feedback Tool and return completed tool to Unit Director/Manager that gives to Nurse. If approved, My Nursing Career Review Panel forwards to CNO for approval. CNO signs and returns to Unit Director/Manager. It is recommended that a business unit maintains a database that reflects completion of old project, initiation of new project and status of certification. If not approved, forms are returned to the Unit Director/ Manager Nurse to give to the Nurse for revision Nurse makes revisions in consultation with Unit Director/Manager and/or Mentor. Resubmits to My Nursing Career Review Panel ASAP. The panel will approve or return for further revision. Process must be completed prior to annual performance review

UPMC My Nursing Career My Professional Contribution Annual Initiation Form *This form must be typed* Name: Employee ID#: Department: Professional Contribution Title: Purpose of professional contribution / identification of problem (Include how the contribution fits into one of the UPMC Nursing Goals): List 3-5 articles or other resources read as part of your background literature review and provide a brief 2-3 sentence summary of each article. (Publication, Title, Date, and Author - do not attach articles): Page 1 of 2

UPMC My Nursing Career My Professional Contribution Annual Initiation Form *This form must be typed* Methodology (explain how you will do your professional contribution or key steps involved) with timeline: Anticipated benefit / outcomes: How will your contribution be measured or evaluated: Employee Signature: Manager Signature: Mentor Signature: Director Signature: Evaluation Panel Feedback: Approved Not Approved CNO Signature: Page 2 of 2

UPMC My Nursing Career My Professional Contribution Annual Outcome Report *This form must be typed* Completion Name: Employee ID#: Department: Attach copy of current certification (If Master s Degree, please note.) You are responsible to maintain the continuing education contact hours required for your certification. Professional Contribution Title: Professional Contribution Completed Professional Contribution Not Completed Professional Contribution in Progress (Explanation required if continuation, complete Initiation Form also.) Please note date project originally started. Please provide a final summary of your professional contribution. Include the following, if relevant: key findings, improvements made, impact on patient care, challenges you experienced and how you handled them, major accomplishments, and recommendation for future contributions. Attach final product, if applicable: ******Retain in department s employee file****** Page 1 of 2

UPMC My Nursing Career My Professional Contribution Annual Outcome Report *This form must be typed* Employee Signature: Manager Signature: Mentor Signature: Director Signature: Performance Review Score: 2.0 or Greater Yes No UPMC Approved Certification current Has satisfactorily completed their identified professional contribution for the past year Needs to provide additional information regarding their work over the past year Additional Information needed: Please provide this additional information to your Unit Director by the following date: Unit Director/Manager: Please return to My Nursing Career Review Panel Has not met the professional contribution outcomes/goals CNO Signature: ******Retain in department s employee file****** Page 2 of 2

Name: Department: UPMC Professional RN Yearly Update To be completed at the time of annual review. (( *This form must be typed* )) Status: FT PT Casual Other Original RN Licensure Years of Active RN Experience: Employee ID#: Cost Center#: Years in Current Specialty: IF NO CHANGE IN EDUCATIONAL DEGREE IN PAST YEAR SKIP TO #4 1. NEW DEGREE IN PAST YEAR: School: Graduation Status: Diploma ADN BSN MSN PhD 2. Additional Nursing Education: (MSN or PhD please attach a copy of your diploma) Degree School Graduation Date 3. Non-Nursing Degrees: Degree School Graduation Date IF NO CHANGE IN CLINICAL CERTIFICATION IN PAST YEAR SKIP TO NUMBER #5 4. Clinical Certifications: (excluding ACLS, CPR complete list of approved certifications in UPMC public folders) (If your certification expired during the past year attach the new certification document with new expiration date.) Certification Expiration Date Certifying Body 5. Did you attend any accredited continuing education programs outside of the hospital in the PAST YEAR ONLY? Yes No If yes, please list: Program Name Sponsored By Date (month/year) Page 1 of 2

UPMC Professional RN Yearly Update To be completed at the time of annual review. (( *This form must be typed* )) 6. Community Projects PAST YEAR ONLY: Certification Expiration Date Certifying Body 7. Professional Recognition Do you belong to any professional organizations? Yes No If yes, please list: 8. Do you hold an office in the organization? Yes No If yes, please list: Organization Position Date of Office Term 9. Have you presented at any local, state, national or international conferences in the PAST YEAR? Yes No If yes, please list: Conference Title Type of Presentation 10. Have you had any articles published in the PAST YEAR? Yes No If yes, please list: Article Published By Date 11. Have you received any awards in the PAST YEAR? Yes No If yes, please list: Name of Award Sponsored By Date Page 2 of 2

This form is used by Management to inform Human Resources about your promotion. (not to be completed by the staff member) UPMC My Nursing Career Promotion Proposal Name Date Employee ID# Department CHECK ONE Proposal for promotion Staff Nurse Professional Staff Nurse (Fill out section 1 & 3) Proposal for promotion Professional Staff Nurse Senior Professional Staff Nurses (Fill out all sections) SECTION 1 Staff Nurse Professional Staff Nurse Professional Staff Nurse Senior Professional Staff Nurse Please check one: 6 months after original slotting or Evaluation/EPR A. Evaluation effective date Performance Rating B. Years of nursing experience C. Degree D. Master s Degree in Nursing Date obtained D. Specialty Certification * Expiration Date * Certification not required if master s degree in nursing is obtained. SECTION 2 Professional Contribution Title/Description: Projected Completion * If detail required, request Senior Staff Nurse Portfolio SECTION 3 Staff Member s Current Salary Merit Increase (if eval) % Amount Promotional increase to Senior Professional Staff Nurse % Amount Final Salary Unit Director/Manager should attach comments and/or performance evaluation for promotions to Sr. Staff Nurse. Attach proposal to EPR & Evaluation (if applicable) along with RPF. Unit Director/Manager Signature Clinical Director Signature CNO Signature Employee Signature Date Date Date Date Approved Not Approved This form is completed by unit director/manager to notify human resources of promotion. RPF must be included.

This form is used by the My Nursing Career Review Panel to objectively score each portfolio and is not returned to the staff member. Name: My Professional Contribution Scoring Tool Department: The Goal identified as most closely associated with their proposed professional contribution: Work Redesign / Clinical Issues Staff Development Recruitment/Retention Patient Satisfaction Patient Education Patient Safety Electronic Health Record Quality Heading Scoring Applicants Score Professional Contribution title Purpose of professional contribution/identification of problem/concern: Summary of Review of literature/current practices (The literature review for the degree completion contribution is waived, when scoring give full credit.) Detailed breakdown /methodology of the professional contribution Anticipated benefits/outcomes of the professional contribution Measurement/evaluation of goals and outcomes 0-Not appropriately reflecting their contribution 1-Appropriate 0-Not clearly defined 1-Poorly defined/identified 2-clearly defined/identified 0-inadequate review: did not cite references in their review of the literature 1-adequate review: cited 3-5 articles (Publication, title, date, author) and gave an adequate summary of the literature and current practices 2-comprehensive review or waived: Cited 5 or more articles (Publication, title, date, author) and gave a comprehensive summary of the literature review and current practices 0-details not reflecting contribution adequately 1-details adequately relate to contribution 2-details well planned and completed 0-outcomes poorly defined 1-outcomes unit based 2-outcomes hospital / system wide 0-measurements inconclusive / non-measurable 1-measurements subjective 2-measurements objective and measurable TOTAL SCORE SCORING: 6 or less: suggest revisions 7 or greater: approved ACTION: Portfolio returned to UD for additional clarification Portfolio accepted Signatures: This is for My Nursing Career Review Panel use only! Do not return to employee.

This form is used to provide feedback to the staff Name: Professional Contribution Title: My Professional Contribution Feedback Tool Department: Thank you for submitting your portfolio It has been reviewed by the My Nursing Career Review Panel Congratulations. Your portfolio was approved! We need additional clarification before we can proceed with accepting your portfolio Heading Scoring Please: Profession contribution title 0-Not appropriately reflecting their contribution 1-Appropriate Revise your title to reflect your true contribution Purpose of contribution identification of problem/concern: 0-Not clearly defined 1-Poorly defined/identified 2-clearly defined/identified More clearly define your problem/concern More clearly identify the purpose of your contribution Summary of Review of literature/current practices 0-inadequate review 1-adequate review 2-comprehensive review Reference the articles that you reviewed ( title, publication, etc) or attach copies of the articles you used Discuss in further detail the review/summary of your review Detailed breakdown /methodology of the professional contribution 0-details not reflecting professional contribution adequately 1-details adequately relate to contribution, but incomplete 2-details well planned and completed More clearly outline the details of how you plan to go about accomplishing your professional contribution Anticipated benefits/outcomes of the professional contribution 0-outcomes poorly defined 1-outcomes unit based 2-outcomes hospital / system wide More clearly identify your anticipated benefits/outcomes of this professional contribution Measurement/evaluation of goals and outcomes 0-measurements inconclusive/non-measurable 1-measurements subjective 2-measurements objective and measurable Provide measurable and objective goals/outcomes by which your contribution can be evaluated You did not include the evaluation of the success of last year s professional contribution on the Completion Form Additional Comments: To prevent a delay in processing your evaluation, please complete and return the above requested information VIA YOUR UNIT DIRECTOR/MANAGER by the following date! Signatures: ****** Copy to employee and retain original in department file. ******