SE - Structural Empowerment

EP20: Describe and demonstrate that nurses at all levels routinely use self-appraisal performance review and peer review, including annual goal setting for the assurance of competence and professional development.


It could not be determined from the narrative description and evidence provided if the CNO routinely uses self-appraisal performance review.
  • Provide narrative explanation and evidence to verify that the CNO routinely uses self-appraisal performance review.


Description and verifying evidence of the completed self-appraisal performance review is provided.

Please refer to Appendix EP20-A for evidence of completed self-appraisal.

The Medical Center is committed to fostering the success of its senior leaders and enhancing their effectiveness in a constructive way. Performance reviews are a means to support this commitment. This process supports both developmental and evaluative outcomes and supports the broad goals of leadership excellence and managerial accountability.

Senior leadership utilizes a goal-based self-appraisal tool. The goals are derived from the overall strategic plan of the hospital and focus on the four pillars which are: financial stability, quality and safety, growth and engagement. Senior leaders are expected to complete their self-appraisal and evaluation and submit to their respective leader for review. This process includes our Chief Nursing Officer and senior Vice President of Patient Care Services, Rita Smith DNP, RN, NEA-BC. The self-evaluation of Dr. Smith includes rating herself based on established and agreed upon goals by the CEO, Joseph Scott, and the level of achievement of those goals from the previous year. Dr. Smith completes a structural format which includes a description and quantification of the goals for the upcoming year. The tool also includes results and evidence of the level of success in the attainment of these goals. A numerical score is entered by Dr. Smith to rate the following: exceeded goal (3), met goal (2), failed to meet expected goal (1).

Dr. Smith reports directly to the Chief Executive Officer of the hospital, Mr. Joseph Scott FACHE. Mr. Scott reviews the self-appraisal form completed by Ms. Smith, reviews projected goals and recommends areas of improvement during a face-to-face discussion.