HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION POLICY NUMBER PERFORMANCE MANAGEMENT EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES APPROVED BY APPLIES TO PURPOSE RESPONSIBILITY Employee 1. Meet with supervisor/manager to establish a Performance Plan at the beginning of the performance cycle. 2. Assist in implementing developmental and corrective action plans that will raise their level of performance and increase contribution. 3. Meet regularly with supervisors/managers to discuss progress on attaining goals. 1. Meet with employee to establish Performance Plan at the beginning of the performance cycle. 2. Monitor ongoing performance and coach employee to ensure that goals are achieved. 3. Complete annual performance review. Positively reinforce and recognize employee. 4. Conduct and document Progress Check(s) with employee, focusing on both positive and developmental feedback. Department Administrator/Director HR, Office HR Service Center Hold supervisor/manager accountable for timely completion of all steps of the performance management process. 1. Send Performance Management reminders to Department Administrator/Director. 2. Conduct periodic audits to determine whether formal performance reviews have been completed on time, the quality of the performance reviews, whether the objectives of this policy are being met. 1. Recalculate review dates for employees returning from leaves of absence. 2. Maintain data in HR Information System to generate salary increases and new PAF. Standards Page 1 of 6
CROSS REFERENCES POLICY This policy defines the process for common and consistent performance management for all employees. The performance management process includes development of a Performance Plan, Progress Check, and an annual Performance Review. The purpose of performance management is to enhance the knowledge, skills and behaviors of all employees throughout the performance cycle in order to achieve organizational goals. This is accomplished by providing a means of measuring employees' effectiveness on the job; identifying areas of development where employees are in need of training, growth, improvement and/or additional resources; maintaining a high level of motivation through feedback with the supervisors/managers and establishing individual performance goals. Please refer to Appendix 1 for a "Glossary of Terms". 1. Initial Assessment Upon employment, managers need to meet with all new hires, transfers and those promoted to inform them of the competencies that must be met during the Initial Assessment period. The Initial Assessment will take place at the end of the assessment period or at the end of orientation, whichever comes later. The method for documenting the initial assessment of competency is as follows: a. Positions that have Skills Checklist - for these positions the skills checklist will serve as the Initial Assessment form. The skills that are required for Initial Competency must be clearly identified. The checklist must be signed and dated by the person conducting the assessment. b. Positions that do not have Skills Checklist - for these positions, managers need to identify on the actual job descriptions which Essential Job Functions and Service standards and/or measures need to be demonstrated during the Initial Assessment period. These items need to be marked with an asterisk (*) on the job description. At the end of the assessment period, the manager must date and initial each item that the employee has met. The manager also needs to sign and date the Initial Assessment line on the Job Description. c. Age-Specific Criteria - if Age-Specific criteria are required for positions, the Age-Specific Checklist needs to indicate which of the criteria must be met during the Initial Assessment period. This document must be dated and initialed at the completion of the assessment period (see Age Specific Criteria packet). A Performance Plan is to be developed at the end of the Initial Assessment period. 2. The Performance Plan Supervisor/manager will meet with each employee at the beginning of his/her performance cycle to develop a Performance Plan. The plan will identify the performance expected of the employee and gain the employee s commitment to perform to those expectations. The supervisor/manager will provide coaching to assist the employee in working toward the performance expectations established in this planning phase. 3. Progress Check Progress Check, an informal review of performance, may be used to determine that goals and objectives are being achieved, to review progress of project work, to recognize achievements, to discuss developmental needs, and/or to provide assistance in the accomplishment of performance goals. Progress Checks should be documented and a copy given to the employee. 4. The Performance Review A formal Performance Review will be conducted for all employees once a year, within 60 days of the anniversary of Standards Page 2 of 6
employment date, date of promotion or date of transfer. NOTE: To the extent that a Leave of Absence results in a change to the employee s anniversary date, the employee s annual Performance Review date will also change (see Leave of Absence Policy). A Performance Review must be completed within 60 days of the effective salary increase (e.g., if a salary increase is due on January 1, a performance review is to be completed between November 1 and March 1). Performance Management reminders will be distributed by Human Resources to Department Administrator/Director for employees with review dates occurring in the next ninety (90) days. Notices to management regarding past due evaluations are also distributed by Human Resources. The supervisor/manager will evaluate employee job performance based on the Essential Job Functions and Service Standards as outlined in the job descriptions. Together, the supervisor/manager and employee will identify strengths, accomplishments and areas for improvement and development. The supervisor/manager will determine a rating based on information gathered regarding performance and discuss the review with employee. A. Reasons for Performance Reviews Performance Review may be conducted for the following reasons: 1. Annual job performance. 2. Determining performance-based salary (merit) increase, if applicable. 3. Supervisor/manager is leaving, transferred or promoted and employee has not had a review in the past six (6) months. 4. Employee is being transferred or promoted and employee has not had a review in the past six (6) months. 5. Establishment of a performance review record for transferred, promoted, demoted or terminated employee. 6. Documenting employee development and continuous performance management. 7. Where performance is deficient, the supervisors/managers will discuss and document specific performance objectives to be met and identify areas for development, training and/or behavioral changes. Together the supervisor/manager and employee will outline the suggested methods and the time frames for correcting deficiencies. At the conclusion of the allotted time, if the deficiencies have not been corrected, the employee may be subject to the disciplinary process for unsatisfactory work performance. B. Required Review, Signatures and Distribution of Copies Upon the completion of the performance review process, signatures are required from the following: 1. Immediate supervisor/manager 2. Next level of management in the department or unit 3. Employee a. The employee s signature will not be interpreted as agreement with the ratings. b. If the employee refuses to sign the performance review, the supervisor/manager will note the refusal on the form and initial it. c. If the employee disagrees with the rating, he/she may give an explanation in the space provided or on a separate sheet that will be attached to the performance review form. The manager should distribute to the Human Resources Service Center- 1. The original, signed copy of the summary (final) page from the Performance Review, Standards Page 3 of 6
2. The Personnel Action Form (PAF) Copies of the above documentation, along with a full copy of the performance review, should also be distributed to: 1. The employee (less the PAF) 2. The employee s departmental file (including age specific criteria testing and observation results and/or skills checklist, as applicable) 5. Establishment of New Review Date A new review date may be calculated for the following reasons by the Human Resources departments listed: a. Return to work from an authorized leave of absence b. Transfers and reassignments c. Promotion d. Demotion 6. Review of Temporary and Contractual Employees All temporary and contractual employees must have job descriptions with established standards and measures and Performance Plans. Supervisors/managers will review employees performance using these standards. Employees will be reviewed at the end of their introductory period and at regular, periodic intervals (minimum annually) thereafter. Every temporary and contractual health care provider will be given a Skills Checklist to be completed on the first day on the job. A tour of the assigned area will be given at the beginning of the shift. The Skills Checklist and the annual performance review will be signed by the employees and the supervisor/managers. A copy of these documents will be kept on file in the department and the original sent to the HR Service Center. PROCEDURE Employee HR, Office of Compensation HR Service Center 1. Meet with employee to develop Performance Plan 2. Monitor ongoing performance and ensure that goals are achieved 3. Conduct Progress Check focusing on both positive and developmental feedback, as applicable. Document session and give copy to employee Work toward performance expectations established in Performance Plan Forward list of employees with review dates occurring in the following ninety (90) days to Department Administrator/Director Generate new PAF if requested by department Standards Page 4 of 6
Department Head Department Head Employee Forward list of employees due for Performance Review to respective supervisor/manager 1. Complete Performance Review within sixty (60) days of the review date. If for any reason the Performance Review cannot be completed within the required 60 days of the due date, please notify the Office of Compensation in writing immediately, and prior to the scheduled salary increase date. 2. Forward review to next level of management for signature and review 3. Positively reward/recognize the employee 1. Evaluate Performance Review. Make changes if warranted, and provide comments 2. Return to supervisor/manager 1. Conduct annual Performance Review discussion with employee 2. Sign and obtain signature of the employee 1. Sign Performance Review indicating that the review has been discussed. 2. If in disagreement with Performance Review, explain dissatisfaction in the space provided on the review form or on a separate sheet. SUPERVISOR /MANAGER HR SERVICE CENTER 1. Forward PAF with Performance Review along with Skills Checklist (where applicable) and Employee Education Record to the HR Service Center 2. Give a copy to the employee 3. Retain copies for the department file 1. Calculate salary increase according to Salary Planning Guidelines. 2. Enter date into HRIS. 3. Forward new PAF to the department for retention in department file SPONSOR Vice President, Human Resources REVIEW CYCLE 3 years FORMS EQUIPMENT REFERENCES Joint Commission on Accreditation of Health Care Organizations (JCAHO) Sections HR.1, HR.3, and HR.4. Standards Page 5 of 6
Fair Labor Standards Act (FLSA) - Equal Pay Bargaining Unit Agreement - Section 6. Wages. APPROVAL: Prepared by Reviewed by Approved By Approved By Latest Revision Approved By Name Signature Date Standards Page 6 of 6