Performance Appraisal for Department Chiefs- 360 Review

CONFIDENTIAL
Department Chief Being Evaluated: _______________________________________
Department:________________________________
Based on your interactions with this Department Chief, please indicate your assessment in the
following areas: (please complete both sides of this form).

1. INTRODUCTIONS

The 360 performance evaluation tool provides many with an opportunity to give valuable
feedback regarding the performance and leadership abilities. In order to provide meaningful
information, you must be honest and direct with your ratings and your comments. All surveys
are anonymous and cannot be traced to the evaluator unless the written comments contain
details to enable identification.
Chief of Staff

2. RELATIONSHIP WITH THE DEPARTMENT CHIEF

The following questions will explain your professional relationship with the Department Chief
2.1 My relationship with this Department Chief is:

A member of the Chiefs Department A physician-leader in another Department

A member of the Senior Leadership Team
2.2 Please identify how often you interact with the Department chief:

Daily Several times a week Once a week 2-3 times per month Once a month or
less

Rating the following competencies : Using the 5-point scale, where

1=all the time
2=most (75%) of the time
3=sometimes (50% of the time)

Performance Appraisal for Department Chiefs- 360 Review

4=not very often (25% of the time) 5=never

3. LEADERSHIP

N/A or
unable to
assess

N/A or
unable to
assess

3.1 Provides clear direction to

others. Aligns the objectives and
practices of multiple teams to
accomplish SMHs mission and
goals.
3.2 Empowers others to make
decisions and takes the time to
facilitate discussions to produce
creative ideas and solutions.
3.3 Follows up and provides
constructive feedback and
recognition to staff on an ongoing basis.
3.4 Takes a leadership role and
accepts accountability; provides
decisive leadership.
3.5 As a leader, promotes
accountability and ensures that
others are accountable for their
work.
Comments or Opportunities for Improvement:

4. BUILDING
RELATIONSHIPS AND
PARTNERSHIPS

4.1 Establishes effective

Performance Appraisal for Department Chiefs- 360 Review

relationships with internal and

external stakeholders.
4.2 Challenges or confronts
stakeholders appropriately
when circumstances warrant.
4.3 Pushes stakeholders to
confront difficult issues when
the benefit to the stakeholder
and SMH is clear.
4.4 Where applicable, brokers
internal partnerships between
medical leaders and
administrative leaders in
decision making.
Comments or Opportunities for Improvement:

5. CHANGE MANAGEMENT
SKILLS

5.1 Creates an environment

conducive to innovation and
learning, an environment that
welcomes change as an
opportunity to improve.
5.2 Reinforces the change vision
with his/her own actions,
behaviours and attitudes.
5.3 Is appropriately both
accessible and responsive.
5.4 s an effective Change
Leader. Understands and
manages the impact of change
on physicians and other
stakeholders.
Comments or Opportunities for Improvement:
3

N/A or
unable to
assess

Performance Appraisal for Department Chiefs- 360 Review

6. COMMUNICATION
SKILLS

N/A or
unable to
assess

N/A or
unable to
assess

N/A or
unable to
assess

6.1 Is effective in
communicating plans,
information and perspective in
spoken form.
6.2 Is effective in
communicating plans,
information and perspective in
written form.
6.3 Is an effective listener.
Comments or Opportunities for Improvement:

7. COMMUNICATION
SKILLS
7.1 Makes positive comments
and provides helpful
suggestions regarding the
development of others.

7.2 Mentors others to realize

their abilities and/or potential
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Performance Appraisal for Department Chiefs- 360 Review

to learn.
7.3 Gives feedback that is
honest, specific and balanced
for developmental purposes.
7.4 Provides ongoing feedback
in behavioural rather than
personal terms.
Comments or Opportunities for Improvement:

8. PERSONAL CREDIBILITY

N/A or
unable to
assess

N/A or
unable to
assess

8.1 Models the behaviours

which are expected of others.
8.2 Is aware of style and impact
on others.
8.3 Is aware of body language,
tone and mannerisms when
dealing with others in stressful
situations.
8.4 Others feel comfortable
discussing issues and difficulties.
8.5 Others are not afraid of
retribution.
Comments or Opportunities for Improvement:

9. CONFLICT RESOLUTION

9.1 Collaborates with key

stakeholders to create a range
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Performance Appraisal for Department Chiefs- 360 Review

of solutions to achieve win-win

solutions.
9.2 Has the ability to facilitate
effectively in conflict situations
and is able to guide others to
achieve resolution.
Comments or Opportunities for Improvement:

10. INNOVATION AND

STRATEGIC BUSINESS
SENSE

10.1 Encourages, supports and

rewards innovation and
creativity.
10.2 Encourages, supports and
rewards quality improvement.
10.3 Develops business plans or
projects on a regular basis to
strategically advance the
department or the hospital.
10.4 Supports the hospitals
strategic focus and helps to
ensure that the hospital
capitalizes on its strengths.
10.5 Challenges traditional ways
of doing business.
Comments or Opportunities for Improvement:

N/A or
unable to
assess

Performance Appraisal for Department Chiefs- 360 Review

11. TEAMWORK AND

COLLABORATION

11.1 Acts to promote

interdependence, good morale,
collaboration and
communications among others.
11.2 Creates a comfortable
environment for creative
decision-making within a team
or group.
11.3 Credits others in public.
11.4 Facilitates beneficial
solutions when conflict arises in
order to improve the function of
the team.
11.5 Shares responsibility with
others for the quality of the
output and for achieving team
objectives.
11.6 Establishes and maintains a
system of rewarding excellence
through recognition,
celebration, communications,
promotion and encouragement.

N/A or
unable to
assess

Comments or Opportunities for Improvement:

12. ACADEMIC
EXPECTATIONS

For each of the following items,

please rate the Department
Chief, based on your personal

N/A or
unable to
assess

Performance Appraisal for Department Chiefs- 360 Review

observations and interactions.

If the Department Chief has
exceeded expectations, specific
comments in the written section
below would be appreciated.
If the Department Chief does
not meet expectations, specific
comments in the written section
below would be expected.
12.1 Striving personally for
educational excellence.
12.2 Striving personally for
research excellence.
12.3 Support of RVHs Mission
and Vision.
12.4 Representing the
Department on academic
matters within the Hospital.
12.5 Representing the
Department on academic
matters at RVH.
Please provide comments or examples illustrating the Department Chief exceeding
expectations:

Please provide comments or examples illustrating the Department Chief NOT MEETING
expectations:

13. OTHER COMMENTS

N/A or
unable to
assess

13.1 Please provide any additional comments to assist the Chief to improve personal or
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Performance Appraisal for Department Chiefs- 360 Review

departmental performance.

N/A or
1
2
3
4
5
unable to
14. THANK YOU
assess
Thank for taking the time to complete this survey. Unless you have provided potentially
identifying comments or clues in your written responses, these surveys are completely
anonymous.
These results in the aggregate, will be used in the annual performance review of the
Department Chief.