Exemplary Professional Practice: Accountability, Competence and Autonomy

EP15 Nurses at all levels engage in periodic formal performance reviews that include a self-appraisal and peer feedback process for assurance of competence and continuous professional development.

EP15b: Provide an example, with supporting evidence, of nurse leaders using periodic formal performance review that includes a self-appraisal and peer feedback process to enhance competence or professional development.

Introduction

The commitment to professional development and competence is a key reason for organizations and regulatory agencies to mandate annual performance evaluations for all members of their staff. For the discipline of nursing, the importance of ongoing professional development and competence is part of the American Nurses Association Code of Ethics, Provision 5.5, “Nurses must maintain competence and strive for excellence in their nursing practice, whatever the role or setting... Continual professional growth, particularly in knowledge and skill, requires a commitment to lifelong learning. Such learning includes continuing education, networking with professional colleagues, self-study, professional reading, specialty certification, and seeking advanced degrees. Nurses must continue to learn about new concepts, evolving issues, concerns, controversies, and healthcare ethics relevant to the current and evolving scope and standards of nursing practice.” The Massachusetts General Hospital (MGH) performance appraisal process provides a structure that allows nurses at all levels to evaluate their practice and identify areas for continued development.

The 2016 MGH Human Resource “Performance Evaluation” policy (attachment EP 15b.a) sets the expectation that performance evaluation is an ongoing process that occurs both informally on a day-to-day basis as well as formally through the use of an evaluation form. The policy states that “The written Performance Evaluation is only one step in this process. It is required that every employee receives this written evaluation of his/her work performance on at least an annual basis. The evaluation shall be based on the employee’s work performance and on expectations/standards communicated to the employee by management.”

The Department of Nursing policy entitled “Registered Nurse Annual Performance Evaluation” (attachment EP 15b.b) states that “nurses who are organizationally accountable for this process (i.e. “nurse manager”) evaluate Registered Nurses This process applies to nurses at all levels of the organization”. The required components of each performance appraisal are: self-evaluation, peer review and manager evaluation. In reviewing these three components the nurse manager and the employee develop and agree on professional development goals for the upcoming year.

The elements of the Nurse Leader performance evaluation include: • Self-evaluation

• Goal-setting • Peer Review • Standards of Behavior—MGH Mission, Credo and Boundaries, confidentiality

agreement • Chief Nurse (or nurse evaluator) evaluation and agreement on goals

A brief review of each element of the Leader evaluation follows. Utilizing the Magnet Model to Evaluate the Nurse Leader Performance Approximately one month prior to the date of their annual performance evaluation, the nurse leader is sent a copy of the evaluation form to complete as part of their self-evaluation. The decision by Jeanette Ives Erickson, RN, DNP, NEA-BC, FAAN, Chief Nurse and Senior Vice President for Patient Care (CNO), to structure the form based on the five components of the Magnet model reflects an organizational commitment to deliver the highest level of nursing care and the accountability of nurse executives for the delivery of that care. The five components and how they are operationalized by nurse executives in Nursing and Patient Care Services (PCS) are: Transformational Leadership:

• Standard: Strategic Planning Outcome: Nurse leader uses strategic planning to design future vision and

outcomes. • Standard: Advocacy & Influence

Outcome: Nurse leader seen as highly credible and have successfully changed mental model where needed, at the staff and executive level so that nursing is viewed as critically important. All parties are aligned with future vision.

• Standard: Visibility Outcome: Strong mutual respect and trust exists between staff and leadership. Both influence each other in the design of future practice.

• Standard: Transformational Thinking Outcome: Lead clinical nurses and nurse leaders to “where they need to be” to meet the demands of the future. Listens, challenges, influences and affirms as the organization moves forward. Acknowledges that transformation may create “controlled turbulence” and involve atypical approaches to solutions. Advances MGH Credo and boundaries.

Structural Empowerment:

• Standard: Professional Engagement Outcome: Promotes, protects and advances the professional culture of the organization. Extends Nursing’s positive influence to professional and community groups through professional contributions

• Standard: Commitment Engagement • Outcome: Clinical nurses and nurse leaders are highly committed to self-

development. They encourage and participate in the development of their peers.

Nurses drive change through their acquired knowledge and align developmental goals with the strategic plan.

• Standard: Teaching and Role Development Outcome: Clinical nurses and nurse leaders serve as effective mentors, teachers and role models within the organization and the profession. Successfully develops creative and adaptive methods for advancing the role of nursing.

• Standard: Commitment to Community Involvement Outcome: Clinical nurses and nurse leaders identify community needs, develop appropriate programs and willingly participate.

• Standard: Recognition of Nursing Outcome: Nursing’s contributions are actively sought and seen as critical to the organization and community in traditional and non-traditional ways.

• Standard: Collaborative Governance Outcome: Nurse leaders support and facilitate staff’s participation in Collaborative Governance.

Exemplary Professional Practice: • Standard: Professional Practice Model

Outcome: Professional Practice Model is enculturated and serves as a roadmap to guide practice.

• Standard: Care Delivery System Outcome: Clinical nurses and nurse leaders are able to independently identify trends, issues, and problems in the care delivery system and implement change. Patients and families are fully engaged and innovative models are in place.

• Standard: Quality care monitoring and improvement Outcome: Clinical nurses and nurse leaders are engaged in collaborating and developing best practices.

• Standard: Culture of safety Outcome: Clinical nurses and nurse leaders are highly engaged with other disciplines to create a culture of safety. Active peer review processes use near misses or potential harm to drive safety.

• Standard: Staffing Scheduling and budgeting Outcome: Clinical nurses own and manage staffing and scheduling. There are formal mechanisms in place for staff to participate in the budgeting and staffing planning process.

• Standard: Interdisciplinary Care Outcome: Clinical nurses and nurse leaders develop interprofessional networks to develop new approaches and solutions across the continuum of care.

• Standard: Accountability, Competence and Autonomy Outcome: Clinical nurses and nurse leaders are highly competent and accountable for practice and seek new approaches. Both are able to provide feedback in formal and informal ways.

• Standard: Ethics, Privacy, Security and Confidentiality Outcome: Clinical nurses and nurse leaders are engaged with other disciplines in developing and maintaining systems that ensure consistent ethical conduct.

• Standard: Diversity and Workplace Advocacy

Outcome: Supports and helps create programs that enhance diversity and ensure delivery of equitable and culturally appropriate care.

• Standard: Clinical Recognition Program Outcome: Nurse leaders promote, support and facilitate staff advancing in the program.

New Knowledge, Innovation and Improvements • Standard: Research • Outcome: Clinical nurses and nurse leaders are actively involved in generating

and disseminating research on a national and international level. • Standard: Evidence-based Practice • Outcome: Clinical nurses and nurse leaders are developing and testing evidence

and translating new knowledge into practice. • Standard: Innovation • Outcome: Clinical nurses and nurse leaders identify, develop, implement and

disseminate innovative approaches through publication and presentations. A culture exists where innovation is valued, encouraged and supported.

Empirical Outcomes • Standard: Nursing makes an essential contribution to patient, nursing workforce,

organizational, and consumer outcomes. • Outcome: The empirical measurement of quality outcomes related to nursing

leadership and clinical practice is imperative and is evident in the above the above four components.

Goal setting Given the central role the nurse leader plays in implementing PCS strategic goals, vision, and values through their work with unit based nursing leadership and interprofessional colleagues, the development and attainment of goals is an important component of their performance evaluation. Goal setting also allows for the identification of opportunities for professional development. Goals are mutually agreed upon by the nurse leader and CNO (or nurse reviewer). Peer Review Peer review is defined by the American Nurses Association as, “the process by which practicing registered nurses systematically assess, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice.” The MGH Nursing Peer Review Tool requires the nurse leader to ask a peer to complete the review. The peer evaluator is asked to select one component that they identify as a strength in the nurse executive practice and one component where there is a practice development opportunity. The form is signed by both the peer evaluator and the nurse executive being reviewed.

Standards of Behavior—MGH Mission, Credo and Boundaries/Confidentiality Agreement All MGH employees annually attest that they will adhere to the hospital’s mission, credo, and boundaries and confidentiality agreements. In doing this, employees commit to the well-being of our patients by providing high-quality, compassionate and culturally-sensitive care and to adhere to all MGH policies and procedures. All MGH employees annually attest that they will uphold their ethical and legal responsibilities to maintain the confidentiality of patients and their health information. Chief Nurse/Nurse Evaluator Evaluation and Agreement on Goals The CNO/Nurse Evaluator receives and reviews the nurse leader’s performance evaluation and writes her comments and reviews the nurse leader’s goals. An example of a performance evaluation of an Associate Chief Nurse (ACN) follows. The ACN is a nurse leader and a member of the nursing executive leadership team who is responsible for ensuring that competent and compassionate patient care is uniformly provided to patients in inpatient, ambulatory, and community settings through development, implementation, and evaluation of policies, programs and services consistent with the hospital’s mission and department’s vision and philosophy. The ACN actively participates in the development of the Department’s strategic plan and provides direction and support to patient care unit leadership toward attainment of short- and long-term goals and objectives. Example Self Evaluation In September 2016, Debra Burke, RN, DNP, NEA-BC, Associate Chief Nurse (ACN), Oncology, Pediatric, Women's Health & Community Nursing Services, was notified by Ives Erickson that her annual performance evaluation was due and she was asked to submit it one week prior to the review scheduled for October 12, 2016 (attachment EP15b.c). In her self-evaluation Burke rated her performance over the past year a five in all components of the performance appraisal. A five is defined as “exceeding expectations, the employee’s performance is outstanding and extends beyond expectations.” Reflecting on her performance in Transformational Leadership and Structural Empowerment, the Burke wrote, “I focus on being a visible and accessible leader. I empower my nurse leaders and role model my expectations. I manage day-to-day operational business, while also keeping the strategic direction and goals ever present so as to move the organization forward.” Burke led the PCS Support Coordination Center for eCare implementation and included an email she received from a colleague on her leadership in that role, “I know I said this to you on Sunday, but you were

masterful in your leadership role. I have been involved in lots of MGH events both planned and unplanned, so I know leadership excellence when I see it.” Burke also noted that at her urging, two of her of her Nursing Directors had applied to DNP programs. In Exemplary Professional Practice, Burke addressed her attention to Nurse Sensitive Indicators (NSI) writing, “We are constantly addressing all NSI and looking for best practices whenever needed. For example two of my units are collaborating on how to improve patient falls with injury – both had been working independently and now see opportunities for synergy”. In New Knowledge Burke completed her Doctorate in Nursing Practice (DNP), and “has submitted my research for publication and have received certification as a Nurse Executive, Advanced”. Woven throughout her self-evaluation Burke identifies achievement of multiple outcomes including:

• Receiving her DNP • Certification as a Nurse Executive-Advanced • Successful implementation of eCare • Encouraging her NDs to return to school to pursue their doctoral studies.

This thoughtful self-evaluation demonstrates Burke’s engagement with activities which promote professional development through her completion of her doctoral education, submission of her research for publication and becoming certified as a Nurse Executive- Advanced. As a nurse leader, she is committed to the professional development of Nursing Directors who report to her by encouraging them to pursue doctoral studies. In reviewing her goals for the previous year, which were:

• Support and drive PCS goals for FY’16 • Advance Autism work • Participate in Palliative Care Unit development • Complete DNP

Burke identified, and the CNO agreed, that she had achieved all of these goals. Peer Review Burke asked her ACN colleague, Dawn Tenney, RN, MSN, Associate Chief Nurse, Perioperative Nursing Service to complete her Peer Review, which Tenney completed on September 19, 2016. Tenney chose to review Burke’s strength in Exemplary Practice focusing on interdisciplinary care. Tenney wrote that Burke has been the MGH liaison to such entities as Spaulding Rehabilitation Hospital, Dana Farber Cancer Center and a number of long term care facilities. Tenney wrote that the Burke “is a role

model to those who work with her on how to be collaborative across disciplines, how to achieve the goals and objectives. Her team looks to her for leadership, support, and knowledge on how to navigate through our systems to assure continuity of care for our patients and families.” Tenney identified an opportunity for practice development in Transformational Leadership regarding strategic planning. She wrote that Burke has “the opportunity to use the resources available at MGH and outside MGH to further develop her ability to do strategic planning for her team/group/service and be able to articulate and present how nursing in those areas can help shape the future.” Tenney encouraged Burke to create forums where she can “present Nursing’s goals and objectives for this (Oncology) service not just for the overall service direction but specifically to nursing.” Burke and Tenney signed the Peer Review form on September 19, 2016. Standards of Behavior—MGH Mission, Credo and Boundaries/Confidentiality Agreement On October 12, 2016 Burke attested that she will abide by the MGH mission, credo and boundary statement and attested that she will abide by the confidentiality agreement. Chief Nurse Evaluation and Agreement on Goals In her evaluation, Ives Erickson recognized the many achievements Burke has had over the past year including the completion of her doctoral education, in recognizing this professional achievement she wrote, “This degree positions Burke well for the future as we work together to give her more hospital-wide opportunities.” Ives Erickson highlighted Burke’s work on two hospital wide initiatives: her leadership of the PCS Support Coordination Center for eCare implementation and her work developing the future organizational structure for Advanced Practice Nurses noting that “with benchmarking completed the hard work of defining staffing models, infrastructure and payment will be complex, but achievable.” Ives Erickson recognized Burke’s many accomplishments including her work with the interprofessional team both within and outside of the MGH, her mastery of the budget process, and the positive response from clinical nurses to her presentation of her capstone, “Characteristics of Nurse Directors that Contribute to High Registered Nurse Satisfaction Scores” during Nurse Recognition Week. Ives Erickson and Burke reviewed and came to agreement on the ACNs goals for 2017 which were: Burke’s N&PCS 2017 Goals:

• Participate in PCS and MGH goals for 2016-2017 (lead initiatives as appropriate) • Expand infusion chair practice on Lunder 9/10 Hematology/Oncology

• Work with the Cancer Center on patient placement and enhance care to off-site locations when possible

• Work with Obstetrics to enhance the postpartum care of women while reducing costs by utilizing a new NP/Midwife practice model

Burke’s Personal 2017 Goals

• Seek opportunities to present research • Increase opportunities to present to large and small audiences to increase

comfort level and improve skill

Ives Erickson agreed with Burke’s goals and signed her performance evaluation on October 12, 2016. The example provided above demonstrates how the various component of the performance evaluation promotes self-reflection through self-evaluation, peer feedback and the evaluation by the CNO supports the nurse leaders’ competence and professional development. References American Nurses Association Code of Ethics with Interpretative Statements (2015) Kansas City, MO. American Nurses Association (1988) Peer Review Guidelines. Silver Springs, MD.

Massachusetts General Hospital Nurse Executive Annual Performance Evaluation Form

Employee Naml\�,eJ,U.l (il)if.

Name and Title of Evaluator:

Employee ID#: Department: /2,M--<U?J:, Effective Date of evaluation: -'/ �c:;._)�

Level5 Exceeds expectations: The employee's performance is outstanding and extends beyond expectations. Level4 Fully meets expectations: Performance meets expectations. Level3 Meets Standards: Acceptable with room for further development. Level2 Needs improvement: Performance not meeting expectations. Improvement necessary. Level 1 Unacceptable: The employee's performance in this area is unacceptable. Immediate improvement must occur.

·, Employee 'SVP- PCS Transformational Transformational Leadership ·Self Assessment

Leadership, Practice ·� "High Performing Developmental Level " Assessment Rating t1 -5) Standards & Outcomes Rati_ng (1-5),

1. Transformational Leadership • Strategic Planning: Staff nurses & nurse leaders use 5strategic planning to design their future vision & can link the plan to tangible outcomes.

• Advocacy & Influence: Nurse leaders seen as highly credible & have successfully changed mental models where needed at the staff & executive level so that nursing is viewed as critically important. All parties are aligned with future vision.

• Visibility, Accessibility, and Communication: Strong mutual respect & trust exists between staff & leadership. Both influence each other in the development & design of future practice.

• Transformational Thinking: Lead staff nurses & nurse leaders "to where they need to be" in order to meet the demands of the future. Listens, challenges, influences & affirms as the organization makes its way into the future. Acknowledges that transformation may create "controlled turbµlence" & involve atypical approaches to solutions. Advances MGH Credo & Boundaries.

2.Structural Empowerment • Professional Engagement: Promotes, protects, & 5 advances the professional culture of the organization. Nurses extend their positive influence to professional & community groups through professional contributions

• Commitment to Professional Development: Staff nurses & nurse leaders are highly committed to self-development. They encourage & participate in the development of peers. Nurses drive change based on their acquired knowledge & are able to align their developmental goals with the nursing strategic plan

• Teaching & Role Development: Staff nurses & nurse leaders function as effective mentors, teachers, & role models both within the organization & within the profession. Successfully develops creative & adaptive methods for advancing the role of nursing

• Commitment to community involvement: Staff nurses & nurse leaders identify community needs, develop

Updated 08/06116 KBW Reference: Wolr, G., Flnlayson, S., Hayden, M, Hoolnhan, S. & Mazzoccoll, A. (2014). Ths developmentallove/s f11 achlevl11g Magnet®designation, Part 1. Joumal of Nursing Admln!:stration, 44 (3), 1l6-141.

5

5

appropriate programs & willingly participate

• Recognition of Nursing: Nursing's contributions are

actively sought & seen as critical to the organization &

community in both traditional & non-traditional ways

• Collaborative Governance: Nurse leaders support &

facilitate staff participation in collaborative governance

3. Exemplary Professional • Professional Practice Model: PPM is fully enculturated & 5 Practice serves as a "roadmap" to guide practice

• Care Delivery System: Staff nurses & nurse leaders are

able to independently identify trends issues, problems in

the care delivery system & implement appropriate

corrections. Patients & families are fully engaged.

Innovative care delivery models are in place

• Quality care monitoring and Improvement: Staff nurses

& nurse leaders are engaged in collaborating &

developing new "best practices" for the profession &

patient specialties

• Culture of Safety: Staff nurses & nurse leaders are

highly engaged with peers & other disciplines to create a

culture of safety. Active peer review processes use

situations involving near misses or potential harm to

drive changes in practice

• Staffing, scheduling & budgeting: Staff nurses "own" &

manage staffing & scheduling, continually looking for

ways to improve effectiveness. There are formal

mechanisms in place for clinical staff to participate in the

budget & staffing planning processes

• Interdisciplinary Care: Staff & leaders develop

interprofessional networks in order to develop new

approaches & solutions to patient management across

the continuum of care

• Accountability, Competence and Autonomy: Staff nurses

& nurse leaders are highly competent & accountable for

practice & seek new approaches. Both are able to

appropriately provide valued peer feedback in both

formal & informal ways

• Ethics, Privacy, Security, and Confidentiality: Nurses &

nurse leaders are highly engaged with other disciplines

in developing & maintaining systems that ensure

consistent ethical conduct

• Diversity and Workplace Advocacy: Supports and helps

create programs that enhance diversity & ensures

delivery of equitable & culturally appropriate care

• Clinical Recognition Program: Nurse leaders promote,

support, & facilitate staff advancing within the clinical

recognition program.

4. New Knowledge, Innovation • Research: Staff nurses & nurse leaders are actively 5 and Improvements involved in generating & disseminating research on a

national or international level

• Evidenced-based Practice: Staff nurses & nurse leaders

are developing & testing evidence & translating new

knowledge into practice

• Innovation: Staff nurses & nurse leaders identify, Updated 08/06/16 KBW Reference: Wolf, G., Finlayson, S .• Hayden, M, Hoolahan, S. & Mazzoccoll, A. (2014). T11e developmental/eveJs in achieving Magnet® dasfgr1slio11, Patt 1. Journal or Nul"$lng Admlnlslrallon, 44 (3), 136·141.

5

5

develop, implement, & disseminate innovative

approaches through publication & presentations. A

culture exists where innovation is valued, encouraged, &

supported.

MGH Performance Appraisal Summary C

Overall Rating (take total score and divide by 4):

Goals/Develooment Section

Review goals for the previous year

• Suppo1t and drive PCS goals for FY 16' - goals met

Employee Self

Assessment

5

• Advance Autism work- hired autism navigator and obtained $100,000 funding grant

SVP-PCS Assessment

s

• Patticipate in Palliative Care Unit development - advancing palliative care work, but no plan for unique unitat this time.

• Finish DNP-met and also received Nurse Research award from MGH.

Were goal(s) achieved?: Yes [ X ] No [ ] Some were achieved, but not all [ NIA [

Incorporating feedback from the self-evaluation, peer review and manager's assessment, the following mutually agreeable goals have been established for the coming year:

PCS Goals:

• Pmiicipate in PCS and Hospital goals for 2016-17 (lead initiatives as appropriate)

• Expand infusion chair practice on Lunder 9/10

• Work with the Cancer Center on patient placement; enhancing care to off-site locations where possible

• Work with OB to enhance the postpmtum care of women while reducing costs by utilizing a new NP/Midwife

practice model

Personal Goals:

• Seek opportunities to present research

• Increase opportunities to present to large and small audiences to increase comfort level and improve skill

Comments Section

Evaluator's Comments:

Employee's Comments:

Transformational Leadership (1)/ Structural Empowerment (2):

My leadership practice is driven by the tenets of transformational leadership. I focus on being a visible and

accessible leader. I empower my nursing leaders and role model my expectations. Updated 08108/16 KBW Rererence: Wolr, G., Finlayson, S., Hayden, M, Hoo1ahan, S. & Mauoccoli, A. (2014). Tho dovelopmenlaflevals in achlevingMagriet®designal/on, Pat1 f. Journal of Nur!.lno Admlnlstrallon, 44 (3), 136-141.

I manage day to day operational business, while also keeping the strategic direction and goals ever present so as to

move the organization forward. My practice areas meet the highest levels of performance in the HCAHPS patient

satisfaction survey in pay for performance targets (quiet at night, responsiveness and pain management).

I led the PCS Support Coordination Center for eCare implementation. I enjoyed taking on this leadership role.

Quotes from two colleagues:

"I know I said it to you on Sunday, but you were masterful in your leadership role. I've been involved in lots of MGH

events, both planned and unplanned, so I know leadership excellence when I see it."

"Just a quick note to share what a great job you're doing at the helm in the SCC. You've been masterful in critically

assessing and revising the processes. I've really enjoyed being pait of your team".

I have two Nurse Directors going back to get their DNP at my urging.

Exemplary Professional Practice (3): Staff and leaders are fully engaged in patient satisfaction, quality and advancing our professional practice model.

We are constantly addressing all nurse sensitive indicators and looking for best practices whenever needed. For example, two of my units are collaborating on how to improve patient fall with injury. Both had been working independently and now see opportunities for synergy. They have been working with the Office of Quality and Safety to also assist in this area.

New Knowledge (4):

Completed my Doctorate in Nursing Practice and submitted my research for publication. Also received certification

as a Nurse Executive.

Precepting new PCS Director of Clinical Informatics.

The signatures indic�e-t�at the employee and evaluator have discussed the information contained in this form. I /' I I

. /, I 1£{1/t,/;J/ _fe{/U l�?Af,u

Emploree's �nature 1,) Date . J ./ I ).l a,,,10 le �--Ail<1 tw-<J;eftfJ1 1 er E �II t)'

Et�uator's Signa:U:e Date I 1

Updated 08/06/16 KBW Re(erence: Wotr, G., Finlayson, S., Hayden, M, Hoolahan, S. & Mazzocco1i. A. (2014). The developmenle//ovo/s fn achieving Magnal®dosignolion, Part 1. Journal of Nursing Admlnlslrallon. 44 (3), 136-141.

MGH Nursing Peer Review Tool - Nursing Leadership

Nursing Peer Review (NPR) "is the process by which practicing registered nurses systematically assess, monitor, and make judgments, about the quality of nursing care provided by peers as measured against

professional standards of practice" (American Nurses Association).

NPR supports nurse autonomy, self-regulation and enhances individual accountability for patient outcomes.

Transformational Leadership D Strength

Structural Empowerment D Strength

Exemplary Professional Practice D Strength

New Knowledge, Innovations & Improvements XO Strength

Empirical Outcomes D Strength

• Select 1 Theme from above and write a brief descriptionExemplary Practice 6

XO Opportunity

D Opportunity

D Opportunity

D Opportunity

D Opportunity

Debbie Burke, Associate Chief Nurse, has spent a number of years while in leadership positions at MGH in developing interdisciplinary networks across Partners. She has been our liaison with outside entities whether Spaulding rehab, the Dana Farber or long term care facilities. She has brought this networking skill to her role of ACN and has established incredible working relationships with her teams, and services for who she is responsible. She works very closely with the MGH Hospital for Children and the Chief of that service, she is developing outstanding working relationships with the MGH Cancer Center, and has had a long standing collaborative practice with the OB/GYN team. She's a role model to those who work with her on how to be collaborative across disciplines, how to achieve the goal and objective without being offensive to anyone. Her team looks to her for leadership, support, and knowledge on how to navigate through our systems to assure continuity of care for our patients and families.

• Select 1 theme from above and write a brief description

Transformational leadership, 1

I think there is an opportunity for Debbie to use the resources available at MGH and outside of MGH to further develop her ability to do strategic planning for her team/groups/services and be able to articulate and present how nursing in those

areas helped shape the future. How does nursing's voice/opinion play into the overall direction that Oncology is going? To have a forum where she can present Nursing's goals and objectives for this service not just the overall service direction

but specifically to nursing.

N'ur ing Leadership Peer !7.valuator Signature

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Date Nursing Leadership Peer Being Reviewed Signature Date

Standards of Behavior - MGH Mission, Credo and Boundaries

Guided by the needs of our patients and their families, we aim to deliver the very best health care in a safe, compassionate environment; we advance that care through innovative research and education; and, we improve the health and well-being of the diverse communities we serve.

As a member of the MGH community and in service of our mission, I believe that: The first priority at MGH is the well-being of our patients, and all our work, including research, teaching and improving the health of the community, should contribute to that goal. Our primary focus is to give the highest quality of care to each patient delivered in a culturally sensitive, compassionate and respectful manner. My colleagues and I are MGH's greatest assets; acknowledging and valuing differences helps us excel. Teamwork and clear communication are essential to providing exceptional care.

As a member of the MGH community and in service of our mission, I will: Provide compassionate, equitable, and patient centered care. Listen and respond to patients, patients' families, caregivers, colleagues and community members. Ensure that the MGH is safe, accessible, inclusive and welcoming to everyone. Share my successes and errors with my colleagues so we can all learn from one another. Make wise use of the hospital's human, financial and environmental resources. Be accountable for my actions. Uphold professional and ethical standards.

As a member of the MGH community and in service of our mission, I will never: Knowingly ignore MGH policies and procedures. Criticize or take action against any member of the MGH community raising or reporting a safety concern. Speak or act disrespectfully toward anyone. Engage in, tolerate or fail to address abusive, disruptive, discriminatory, or culturally insensitive behaviors. Look up or discuss private information about patients or staff for any purpose outside of my specified job responsibilities. Work while impaired by any substance or condition that compromises my ability to function safely and competently.

' /// i/ I / .,.,; ; ,{, l (,//IA' �r l \_,,/_,g _

Signature Prfrit Name

Confidentiality Agreement

Partners HealthCare System, its affiliates and joint venturers, have a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their health information. Additionally, Partners HealthCare System, its affiliates and joint venturers must assure the confidentiality of its patient, fiscal, research, computer systems, management and other business information. In the course of my employment/assignment at a Partners organization/practice, I may come into the possession of confidential information. In addition, my personal access code [User ID and Password] used to access computer systems is also an integral aspect of this confidential information.

By signing this document I understand the following:

1. Access to confidential information without a patient care/business need-to-know in order to performmy job - whether or not that information is inappropriately shared - is a violation of this policy. I agreenot to disclose confidential or proprietary patient care and/or business information to outsiders(including family or friends) or to other employees who do not have a need-to-know.

2. I agree not to discuss confidential patient, fiscal, research, computer systems, management andother business information, where others can overhear the conversation, e.g., in hallways, onelevators, in the cafeterias, on the shuttle buses, on public transportation, at restaurants, at socialevents. It is not acceptable to discuss clinical information in public areas even if a patient's name isnot used. This can raise doubts with patients and visitors about our respect for their privacy.

3. I agree not to make inquiries for other personnel who do not have proper authority.

4. I know that I am responsible for information that is accessed with my password. I am responsiblefor every action that is made while using that password. Thus, I agree not to willingly inform anotherperson of my computer password or knowingly use another person's computer password instead of my own.

5. I agree not to make any unauthorized transmissions, inquiries, modifications, or purgings of data inthe system. Such unauthorized transmissions include, but are not limited to, removing and/ortransferring data from Partner's computer systems to unauthorized locations, e.g., home.

6. I agree to log off a Partners workstation prior to leaving it unattended. I know that if I do not log off acomputer and someone else accesses confidential information while the computer is logged on withmy password, I am responsible for the information that is accessed.

Partners HealthCare System, its affiliates and joint venturers, and Partners Community HealthCare have the ability to track and monitor access to on-line records and reserves the right to do so. Partners HealthCare System, its affiliates and joint venturers, and Partners Community HealthCare can verify that those who accessed records did so appropriately.

I have read the above special agreement and agree to make only authorized entries for inquiry and changes into the system and to keep all information described above confidential. I understand that violation of this agreement may result in corrective action, up to and including termination of employment and/or suspension and loss of privileges. I understand that in order for any User ID and/or Password to be issued to me, this form must be completed.

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2016 Performance Review

Debra Burke

Date: October 12, 2016

May 1, 2002 was a great day as Debbie Burke launched her associate chief nurse career. Prior to this, Debbie was a nursing director whose work I admired. She and I would meet periodically as she helped me on numerous occasions as I entered my CNO role in 1996. Debbie was a good sounding board while at the same time truly engaged in the mentoring I provided. As the new department of nursing organizational structure was crystalized, I knew that Debbie would be a great addition to the executive team. I was delighted when she accepted my offer. It has been a great journey for 14 years

) Watching Debbie grow and

contribute has been one of the highlights of my career.

I was happy when Debbie took my advice to obtain a doctoral degree. Her graduation this past year was the culmination of hard work and wisdom. This degree positions Debbie well for the future as we work together to give her more hospital wide opportunities. Two such opportunities emerged this past year. I asked Debbie to be the operational lead for Nursing and PCS Go live with eCare. Her work leading was well done .. The second major activity is developing the future organizational structure for advanced practice nurses. With benchmarking completed the hard work of defining staffing models, infrastructure and payment will be complex but achievable.

It is good to have a formal conversation about the work that Debbie has been doing this past year. She is an invaluable, thoughtful, productive and talented leader. Debbie has contributed to our work in numerous ways. In her own performance review and in the peer review the contributions are documented. However, it is important for me to point out that she does so much more by being a leader within own area of responsibility as well as across our organization.

Unique contributions include the outcomes we achieved as a team (see PCS annual strategic plan). I am especially proud of the development and implementation of eCare. By all accounts, MGH was incredibly successful in every aspect of this work. The enormity only made us better as individuals, as a team and as leaders. Debbie supported our eCare residency program and her team paved the way for success.

Debbie has been thoughtful in reflecting on the issues of diversity and inclusion. I anticipate that we will need to focus and should focus a great deal of time and energy on implementing the strategies from our diversity committee.

Partners 2.0 will be new work but there is a true need to embrace the desire for culture change. Together we will preserve the precious mission of the MGH while enhancing our work as a system.

The support of our workforce during these turbulent times is a core priority. Ensuring direct engagement with staff will be core. In addition working with line managers to help to enhance the environment of care that is healing, Evidence based will be important. OUR new PPM provides a unique opportunity to engage staff many important initiatives.

Specific to the work she has done, I want to recognize the outcomes achieved. • Working with physician colleagues solving many issues• Supporting social work on issues related to Child Protection• Mastering this year's budget process• Selecting new talented team members• Focusing on building relationships in the Cancer Center• Supporting the work with the Shrine• Preparing her leaders for the threatened nursing strike at BWH• The nursing staff very well received her presentation of her capstone during this year's

nurse recognition week event.

Going forward, we have important work to do together. As a great team I know we can do whatever we decide to do. I remain grateful having Debbie on our team.

/-,

//c/4,11 I it� Debra Burke -

MASSACHUSETTS GENERAL HOSPITAL Department of Nursing

TITLE: REGISTERED NURSE ANNUAL PERFORMANCE EVALUATION

Overview:

This policy is to be used in conjunction with the Massachusetts General Hospital (MGH) Human Resources Performance Evaluation policy. Nurses who are organizationally accountable for this process (i.e. “nurse manager”) evaluate the Registered Nurse (RN). This process applies to nurses at all levels of the organization.

The required components of each annual performance evaluation are: 1) Self-evaluation

• The Registered Nurse (RN) completes a self-evaluation with goals, and may include aclinical narrative.

2) Peer review• The RN requests a peer review from a colleague.• The peer review includes two aspects of a nurse’s practice: recognizing practice strength

and identifying a practice development opportunity to assist a peer in developing goals toenhance or advance an aspect of nursing practice.

3) Manager evaluation• The nurse manager reviews the RN’s self-evaluation and peer review and completes

his/her own assessment.

It is through the process of the nurse manager and the employee reviewing these three components of the annual performance evaluation that leads to the mutual development of the nurse’s clinical and professional goals for the upcoming year.

In addition to the annual performance evaluation, each year, topics are chosen and included as part of the Annual Regulatory Compliance Training program. The topics include, but are not limited to, job expectations, local, state or federal regulations, standards, rules of participation, accreditation or licensure requirements. The employee is expected to demonstrate initial and ongoing knowledge of, and compliance with all areas, including each of the selected topics. Documentation of the employee’s compliance with the Annual Regulatory Compliance Training Program is completed, at a minimum of one time per year.

Approved by Nursing Executive Operations Team, 8/2009 Approved by Nursing Executive Operations Team, 7/2012 Approved by Nursing Executive Operations Team, 5/2017

Massachusetts General Hospital Human Resources Manual

PERFORMANCE EVALUATION (2016)

APPLIES TO: Weekly paid employees

1. POLICY

1.1. It is expected that the process of Performance Evaluation be an ongoingdialogue that occurs informally on a day-to-day basis. The written Performance Evaluation is only one step in this process. It is required that every employee receives this written evaluation of his/her work performance on at least an annual basis. The evaluation shall be based on the employee's work performance and on expectations/standards communicated to the employee by management. If an employee holds more than one position, the employee shall receive a written evaluation for each position and a transaction must be made for each job to process an increase. Such evaluation shall consist of three parts:

1 .1.1. A written evaluation using a Hospital approved form,

1.1.2. A personal discussion of the evaluation between the evaluator and the employee, and

1 .1.3. Follow-up in the form of employee counseling and ongoing review of established goals and action plans, as appropriate.

2. DEFINITIONS AND REGULATIONS

2.1. Key objectives of Performance Evaluation are as follows:

2.1.1. To facilitate communication between employees and their immediate supervisors concerning work performance;

2.1.2. To help employees better understand what is expected of them in terms of job performance;

2.1.3. To identify strengths along with areas needing improvement, to highlight successes, and to provide a basis for counseling and training;

2.1.4. To improve employee productivity, quality of service and customer relations;

2.1.5. To provide valid and objective data to support various personnel management decisions such as retention, advancement and compensation; to provide documentation of communication between the employee and immediate supervisor concerning the employee's overall work performance, and to comply with regulatory agency reporting requirements;

2.1.6. To improve use of human, financial and material resources;

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2.1.7. To receive feedback from the employee concerning his/her perception of the evaluation and how s/he is being managed.

2.2. The Performance Evaluation process is a responsibility for which MGH supervisory and managerial personnel are directly accountable. Providing ongoing verbal feedback and completing the written Performance Evaluation are considered primary management responsibilities. How effectively these responsibilities are carried out will be taken into consideration when the supervisor or manager him/herself is evaluated.

2.3. Each employee shall have the right to examine the written Performance Evaluation, dispute inaccuracies and make written comments concerning all aspects of the evaluation. Any written comments the employee makes regarding the evaluation shall be made a part of his/her employment record. Each employee is entitled to receive a copy of his/her Performance Evaluation.

2.4. Written Performance Evaluations shall be made part of each employee's permanent employment record and should be treated as confidential information.

2.5. Frequency of Formal Performance Evaluation:

2.5.1. Formal, documented evaluation of employee work performance must be accomplished at a minimum of once each year. However, the manager/supervisor may conduct such evaluation more frequently if s/he determines it appropriate, or at the specific request of the employee.

2.5.2. An employee leaving a department, either by termination (i.e. voluntary resignation vs. discharge or resignation requested), or due to transfer, should receive a formal written Performance Evaluation prior to the effective date of such change. A copy of the evaluation shall be placed in the employee's employment record to serve as a final evaluation of the employee's performance in the last held position. The employee is entitled to receive a copy of the evaluation.

2.6. Concerns with Performance Evaluations are not grievable via the MGH grievance process. Human Resources should be utilized, as appropriate, to assist in resolving issues with Performance Evaluations.

2. 7. The next review date will be automatically calculated from the previousnext review date.

2.8. Employee will not have the ability to change the next review date unless HR is consulted.

2.9. If employee receives more than one merit increase/performance review per year, HR needs to be consulted.

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3. PROCEDURES

Responsibility

Human Resources

Department Heads and Supervisors

Related Policies: Multiple Jobs

Action

1. Provides training and on-going support tomanagers and supervisors pertinent toPerformance Evaluation.

2. Provides standard forms for use in Performance Evaluation and employee development planning.

3. Establishes and maintains performance evaluation tracking system.

4.

5. Completes written evaluation by date indicated, using Hospital-approved format.

6. Discusses Performance Evaluation withemployee; prepares development plan asappropriate.

7. Enters merit increase into PeopleSoft andforwards copy of completed documentation ofPerformance Evaluation to Human Resourcesin a timely manner.

8. All paper Performance Evaluations need to besent to Employee Records.

Transfers and Promotions

Last Revision: 2016

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