PERFORMANCE EVALUATION INSTRUCTIONS:  SCORE EACH CATEGORY BASED ON THE FOLLOWING CRITERIA:

3 MEETS AND EXCEEDS ALL STANDARDS

2 MEETS ALL STANDARDS

1 MEETS SOME STANDARDS -SOME IMPROVEMENT NEEDED

0 IMPROVEMENT NEEDED

***NOTE: Please refer to “Position Responsibilities and Evaluation Ratings” for more detailed information about the ratings.

METHOD:  (O) OBSERVATION  (D) DEMONSTRATION (V) VERBALIZED

RATING

1.

Competently performs clinical and physiological assessment of patients as related to the cardiopulmonary system for all ages served.  Is able to integrate data and act as a consultant to the medical staff for optimizing respiratory therapy. 

2.

Evaluates patient response to therapy, including pain, and identifies the need for further assessment and/or revise the need for respiratory therapy.  Initiates appropriate nurse and physician contact for intervention if needed.  (age specific)

3.

Knowledgeable of directives involving “No Code” policy.

4.

Knowledgeable in the procedure for obtaining arterial blood specimens for blood gas analysis and understands the possible complications and contraindications associated with the procedure.

5.

Demonstrates knowledge and understanding of the differences in techniques and treatment modalities as performed on patients of varying ages (age specific).

6.

 Demonstrates knowledge and understanding of oxygen concentrations and medication doses as they relate to patients of varying ages (age specific).

7.

Verbalizes an accurate knowledge of P&Ps regarding response times to QH, QID, TID, BID, NOW, ASAP, STAT, ER, ICU, L&D, Code Blue and Code Pink responses.

8.

Demonstrates ability to assess patient, his/her needs, and ability to tolerate treatment and reassessment for response to treatment.

RATING

1.

Demonstrates accurate administration of respiratory medications; verbalizes knowledge of restrictions/precautions that apply to medication administration; recognizes generic/trade drug names.

2.

Sets up and monitors mechanical ventilators and the associated critical care duties needed for such treatment, such as airway management and tracheal suctioning.

3.

Consults with other healthcare providers to formulate a teaching plan based on identified learning needs of a patient and evaluates effectiveness of learning; includes patient's family in the teaching as appropriate. 

4.

Coordinates and directs patient care to ensure patients' needs are met and that hospital policy is followed. Treats patients and their families with respect and dignity.

5.

Performs all aspects of direct patient care in an environment that optimizes patient safety.

6.

Performs EKGs utilizing proper electrode placement, performs mechanical/tracing troubleshooting and recognizes severely abnormal results for physician notification, sends reports to physicians who requested them and files reports in department according to department procedures. (age specific)

7.

Demonstrates competency to perform IPPB or alternative modes (EZPAP) using mouth seal & mouthpiece therapy; knowledge of indications, contraindications and hazards of therapy (age-specific).

8.

Performs Allens test properly and indicates its purpose; performs safe sample analysis (age-specific).

9.

Demonstrates competency to perform free-flow nebulizer therapy using mask, mouthpiece, and blow-by/mask for infants; knowledge of indications, contraindications and hazards of therapy (age-specific).

10.

Demonstrates competency to perform metered-dose inhaler (MDI) therapy using spacer devices, proper instruction for patient use, knowledge of indications, contraindications and hazards of therapy; knowledge of drug interactions with same-drug liquid doses (age-specific), contraindications and hazards of therapy (age- specific).

11.

Demonstrates competency to properly instruct patient on Incentive Spirometry exercises, optimizing patient under- standing and compliance to perform on own, knowledge to utilize alternative methods (EZPAP) for non-compliance or ineffective outcomes; knowledge of indications, contraindications and hazards of therapy (age-specific).

12.

Demonstrates competency to properly administer oxygen therapy via nasal cannula, simple mask, venturi-mask, non/partial rebreather mask, high-flow and humidifier setups, Bird blenders for infant hoods, portable oxygen tank use, use of flowmeters, flowmeters with power take-off, oxygen regulators; knowledge of indications, contra- indications, hazards and optimal titration practices (age-specific).

13.

Demonstrates competency to properly administer aerosol therapy via large volume nebulizer, instructions and education to patient and/or parents; knowledge on indications, contraindications, hazards of therapy and optimal titration practices (age-specific).

14.

Demonstrates competency in safe and proper performance of sputum induction; knowledge of tonicity of saline used; knowledge of indications, contraindications and hazards of procedure; knowledge of proper sample handling to Clinical Laboratory and required requisitions/paperwork/documentation (age-specific).

15.

Demonstrates competency to perform unit specific ventilator/ventilation management setup, Operation Verification Procedure (OVP) and safe and proper use; competency in ventilator weaning techniques and parameter interpretation (age- specific).

16.

Demonstrates competency in safe and proper performance of suctioning (tracheal, nasotracheal, orotracheal); safe and proper use of suction catheters; knowledge of indications, contraindications and hazards; knowledge to Clinical Laboratory and required requisitions/paperwork/documentation (age-specific).

17.

Demonstrates competency in airway management of endotracheal tubes, tracheostomy tubes, ETT/trach care, ETT taping/re-taping/repositioning; knowledge to identify skin integrity changes with ETT/trach tubes; knowledge of indications, contraindications and hazards of airway maintenance (age-specific).

18.

Demonstrates competency to assist with endotracheal intubation; setup of intubation tray and supplies; verification of tube cuff competency; cricoid pressure, proper tube placement and tube securement; knowledge of indications, contraindications and hazards (age-specific).

19.

Demonstrates competency in safe patient transfers and transports (internal, external); checks necessary equipment on crash carts, resuscitation bag, oxygen cylinder pressures.

20.

Demonstrates competency operating department’s  blood gas analyzers, knowledge on calibration, trouble- shooting, preventive maintenance and quality control analysis; knowledge of panic values and immediate notification to physician (age-specific).

21.

Demonstrates competency to setup pulse oximeters, rapid correlation and interpretation of oximetry values, setup of all alarm parameters; troubleshooting interventions and what appropriate action to take for abnormal values (age-specific).

22.

 Demonstrates ability to recognize normal and abnormal signs of growth in the newborn to geriatric patient and the ability to act on abnormal findings (age-specific).

23.

Follow’s hospital and departmental infection control policies and procedures.

24.

Documents all pertinent data on the patient’s medical record following completion of any service.

25.

Competent in performing employee and patient skin testing and measurement of skin test results.  Provides accurate documentation of test results according to department procedure.

26.

Competently assists with bronchoscopy and laryngoscopy procedures, including equipment / supply set up, patient preparation, monitoring of the patient, laboratory specimen processing, cleaning of equipment, leakage testing of scopes.  Knowledgeable of radiologic concerns for fluoroscopy procedures.

27.

Performs transcutaneous oxygen studies, including maintenance and calibration of electrodes, obtains optimum measurement of selected sites.

28.

Attends and maintains mandatory training in safe patient handling, trained in safe lifting techniques, includes but not limited to 1. Appropriate use of lifting devices and equipment, 2. Five areas of body exposure: vertical, lateral, bariatric repositioning and ambulation 3. Use of lifting devices to handle patients safely.

29.

Performs other duties as assigned or required.

RATING

1.

Independently recognizes and performs duties which need to be done without being directly assigned.  Establishes priorities; organizes work and time to meet them.

2.

Recognizes and responds to priorities, accepts changes and new ideas.  Has insight into problems and the ability to develop workable alternatives.

3.

Accepts constructive criticism in a positive manner.

4.

Adheres to attendance and punctuality requirements per hospital policy.  Provides proper notification for absences and tardiness. Takes corrective action to prevent recurring absences or tardiness.

5.

Uses time effectively and constructively. Does not abuse supplies, equipment, and service.

6.

Observes all hospital and departmental policies governing conduct while at work (e.g., telephone and computer use, electronic messaging, smoking regulations, parking, breaks and other related policies).

RATING

1.

Patient-Centered: Respectful of and responds to patients preferences, values and needs

2.

Accountability & Customer Focused: Participates actively and positively affects the outcomes of customer service activities

3.

Teamwork & Communication: Is a team player and communicates effectively at all levels

4.

Privacy & Safety:  Follow and abide by all privacy (HIPAA) regulations regarding patient information

5.

Attitude & Respect:   Being sensitive to customer/co-worker emotions, thoughts, and feelings by being culturally aware of their preferences and cultural norms in a courteous and professional manner

RATING

1.

Understands and abides by all departmental policies and procedures and is knowledgeable and complies with federal, state, and local laws that govern business practices as well as all accreditation standards that apply to the position.

2.

Conducts business in an ethical and trustworthy manner at all times.

RATING

1.

Attends scheduled in-service and mandatory in-service. Communicates ideas to supervisor for a safer layout of equipment, tools, and/or processes.

2.

Follows standard precautions and transmission based precautions.

3.

Adheres to procedure for proper disposal of medical sharps, pharmaceutical and medical waste per hospital policy.

4.

Is knowledgeable in the hospital safety program and takes necessary steps to maintain a safe environment.  Adheres to safe work practices in order to prevent injuries and illnesses.

5.

Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes

RATING

1.

Active participant in Continuous Quality Improvement program by assisting in finding new and better ways of performing duties and responsibilities.

2.

Understands performance improvement concepts and demonstrates understanding by:

a)    Defining performance improvement, and verbalizing at least one major goal of the performance improvement program within the hospital setting.

b)    Able to verbalize at least one departmental or hospital wide improvement initiative that has occurred within the last 12 months.

POSITION TITLE:

RCP II

DEPARTMENT:

Cardiopulmonary

Instructions: The frequency indicated reflects the requirements for normal working hours.  Please indicate (X) the essential physical requirements for this position.  Reasonable accommodations will be made as necessary.

PHYSICAL REQUIREMENTS

A.

SITTING:

I.

WRIST DEVIATION (SIDE TO SIDE):

1.  Never (0 hours)

1.

Never (0 hours)

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

B.

STANDING:

J.

HAND/WRIST REPETITIONS (UP AND DOWN):

1.  Never (0 hours)

1.

Never (0 hours)

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

C.

WALKING:

K.

REACHING:

1.  Never (0 hours )

1.

Never (0 hours)

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

D.

LIFTS AND CARRIES:

FREQUENCY:

2.  11 to 24 pounds

Never

Occasionally

Frequently

Constantly

3.  25 to 34 pounds

Never

Occasionally

Frequently

Constantly

4.  35 to 50 pounds

Never

Occasionally

Frequently

Constantly

5.  51 to 74 pounds

Never

Occasionally

Frequently

Constantly

6.  75 to 100 pounds

Never

Occasionally

Frequently

Constantly

7.  Over 100 pounds

Never

Occasionally

Frequently

Constantly

E.

LIFTS OVERHEAD:

FREQUENCY:

1.  < 10 pounds

Never

Occasionally

Frequently

Constantly

2.  11 to 24 pounds

Never

Occasionally

Frequently

Constantly

3.  25 to 34 pounds

Never

Occasionally

Frequently

Constantly

4.  35 to 50 pounds

Never

Occasionally

Frequently

Constantly

5.  51 to 74 pounds

Never

Occasionally

Frequently

Constantly

6.  75 to 100 pounds

Never

Occasionally

Frequently

Constantly

7.  Over 100 pounds

Never

Occasionally

Frequently

Constantly

F.

TWISTING:

L.

GRASPING:

1.  Never (0 hours )

1.

Never (0 hours )

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

G.

BENDING:

M.

PULLING:

1.  Never (0 hours )

1.

Never (0 hours )

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

H.

SQUATTING/KNEELING/CRAWLING/CLIMBING:

N.

PUSHING:

1.  Never (0 hours )

1.

Never (0 hours )

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

PHYSICAL REQUIREMENTS cont.

O.

GROSS MOTOR MOVEMENTS:

Q.

FINE MOTOR MOVEMENTS:

1.  Never (0 hours)

1.

Never (0 hours)

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

VISUAL REQUIREMENTS

HEARING

P.

VISUAL REQUIREMENTS:

R.

HEARING REQUIREMENTS:

1.  Close eye work (small figures)

1.

Special requirements (please

2.  Color discrimination

specify)

     - Minimal color discrimination

     - Normal color discrimination

3.  Other

WORKING CONDITIONS

S.

TEMPERATURE:

X.

NON-IONIZING RADIATION (WELDING FLASH MICROWAVES, SUN, ETC.):

1.  < 15 Degrees Fahrenheit

1.

Never (0 hours)

2.  Between 16 and 95 degrees

2.

Occasionally (< 3 hours daily)

3.  > 95 degrees

3.

Frequently (3-6 hours daily)

4.

Constantly (> 6-8 hours daily)

T.

ELEVATIONS:

Y.

IONIZING RADIATION (X-RAY, RADIOACTIVE ISOTOPES):

1.  Work < 5        feet above ground

1.

Never (0 hours )

2.  Work 5 – 9     feet above ground

2.

Occasionally (< 3 hours daily)

3.  Work 10 – 15 feet above ground

3.

Frequently (3-6 hours daily)

4.  Work > 15      feet above ground

4.

Constantly (> 6-8 hours daily)

U.

CRAWL SPACE/CRAMPED POSITION:

Z.

NOISE (LOUD/REPETITIVE, <85 DECIBELS PER OSHA STANDARD):

1.  Never (0 hours )

1.

Never (0 hours )

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

V.

HAZARDOUS EXPOSURE (CHEMICAL {E.G. LATEX} & INFECTIONS):

Z1.

PERSONAL PROTECTIVE EQUIPMENT (E.G. RESPIRATORY MASK, ETC.):

1.  Never (0 hours )

1.

Never (0 hours )

2.  Occasionally (< 3 hours daily)

2.

Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

3.

Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

4.

Constantly (> 6-8 hours daily)

W.

SQUATTING/KNEELING/CRAWLING/CLIMBING:

1.  Never (0 hours )

2.  Occasionally (< 3 hours daily)

3.  Frequently (3-6 hours daily)

4.  Constantly (> 6-8 hours daily)

Telephones

Calculator

Telephones

Copy Machine

Payroll System

FAX Machines

Computer/Laptop

 Pager System

Other: Specify

OSHA BLOODBORNE PATHOGENS CATEGORY CLASSIFICATION

I ________________________________________ understand that the duties that are required of me in my job position places me in a Category:  

 Priority A   (Frequent Exposure)          

 Priority B   (Occasional Exposure)

 Priority C (No Anticipated Exposure)

Employee's Signature:

Date:

Supervisor's Signature:

Date:

POSITION RESPONSIBILITIES AND EVALUATION RATINGS

Indicators of Performance Level

3

Exceptional – Meets and Exceeds All Standards

Performance of this caliber is extremely rare.  It is a rating that should be reserved for those who clearly and consistently demonstrate extraordinary and exceptional accomplishments in all major areas of responsibility.  Employees who perform at this level are easily recognized by their peers as well as others outside their own group and as well as those in related areas.  It is a level of performance that is seldom equaled by others who hold positions of comparable scope and responsibility.

2

Meets All Standards

This rating should be assigned to those whose demonstrated performance clearly meets all the requirements of the position in terms of quality and quantity of output.  It is performance normally expected of those who have the necessary education, training and relevant experience to enable them to effectively perform in a consistently reliable and professional manner.  Although minor deviations may occasionally occur, the overall level of performance meets or may slightly exceed major job duties

1

Meets Some Standards – Needs Improvement

This is a performance level that does not fully meet job requirements in all areas of major responsibilities.  The individual may demonstrate the ability to complete most assignments; however, the need for further development and improvement is clearly recognized.  This individual needs coaching and counseling to fully meet the requirements of the position.  The employee is approaching meeting the expectations, but may be a new employee and not fully expected to meet all job requirements at this time.

0

Immediate Improvement Needed

This is a performance level that does not meet job requirements in all areas of major responsibilities.  The individual may demonstrate the ability to complete some assignments; however, the need for immediate development and improvement is clearly recognized.  This individual needs constant coaching and counseling to fully meet the requirements of the position.  This category describes a level of performance, which should significantly improve within a reasonable period if the individual is to remain in the position.

CATEGORY

NUMBER OF COMPONENTS

CATEGORY TOTAL SCORE

RESULTS

(Score: by # of Components)

COMMENTS

SECTION I – Performance Accountability

A.  Knowledge of Work

B.  Duties and Responsibilities

C.  Initiative and Judgment/ Attendance and Reliability

SECTION II – Service Excellence

Service Excellence

SECTION III – Continuous Quality Improvement

A.  Corporate Integrity

B.  Education and Environment of Care

C.  Continuous Quality Improvement

FINAL RESULTS

Total Comp

Total Score

Final Results in %

GOALS:

EMPLOYEE’S COMMENTS:

SUPERVISOR’S COMMENTS:  (Summarize strengths and areas needing improvement.  Indicate development plans for improving performance during the next appraisal period)

1

Employee’s Signature

Date:

Department Manager’s Signature

Date:

Human Resources  Department Acknowledgment

Date: