ࡱ>  bjbj .FhhtZ3q:::qqqqqqqs9vzq::::qq6 6 6 :q6 :q6 6 tiT4qPq0V(mbpqq0qrmv~v4qv4q<::6 :::::qq:::q::::v::::::::: : 360-DEGREE EVALUATION FORM SELF-ASSESSMENT For use by a Resident INTERPERSONAL AND COMMUNICATION SKILLS Background Information The LSUHSC Neurology Residency Program is using a 360-degree assessment system for residents. 360-degree assessment is a way of providing feedback about progress by placing the person to be evaluated at the hub of the wheel thus reflecting the center from all sides.      This process provides a full-circle view of resident skills and abilities by gathering information from various perspectives: the individual and others (peers, supervisors, patients, and health care team members). This profile provides a more balanced overview than supervisor review. The completed questionnaires will be compiled into a final report for you. Anonymity for those completing the report ensures that ratings and comments are fair as well as skill and behavior based. You will receive a report that will provide you with anonymous scores and comments from each individual as well as your own for comparison purposes. It is intended that all feedback will assist you in tracking your perceptions of your progress and noting where improvement or adjustment is needed. Your honest comments and ratings are extremely valuable to the process. Please rate yourself for the recent time period. Be realistic, honest, and direct. This is a formative evaluation process (one designed to provide feedback for improvement) not a summative one (designed for promotion or retention purposes). Tips for Giving Useful Written Comments Useful comments give examples of specific behaviors. For example: "Im unreliable" is not specific. A much more useful comment would be: "I was absent from two of our last three journal club sessions without letting anyone know in advance. Ask yourself: "Will my comments guide me to improve? Or, you may list the specific actions you wish to continue (that have provided success in the past). Consider stating the impact of the action you observed so consequences of behavior are realized. This helps with motivation to improve. Example: Benchmark: Uses effective listening skills to elicit information Comment: Needs some improvement here. This is too vague. Better comment: When Im with a patient I sometimes feel that Im not really listening because Im so worried about how far behind Im getting or because the patient is repeating things over and over. I might seem distracted. If the patient senses this, they may feel unimportant. It is especially important to take the time to enter narrative comments in the text boxes provided. The value of the 360-process is largely dependent on you and others being thoughtful, candid and, where appropriate, constructively critical. COMPETENCE IN INTERPERSONAL/COMMUNICATION SKILLS Your Name_____________________________________________________________ Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional associates. Score the following boxes as shown below to indicate how often you observed the behavior NA1234Not ApplicableI rarely demonstrates (<25% of the time)I do this Sometimes (25-50% of the time)I do this most of the time (50-75% of the time)I do this all the time (>75% of time) Competency: Communicate effectively to create and sustain a therapeutic relationship with patients and families.Knowledge/Skills/Attitudes Benchmarks:I obtains historical information from appropriate individual (patient, caregiver, etc)NA1234I makes appropriate introductions and explains personnel rolesNA1234I respects privacy of patient/family by using various areas in facility for conversations, exams, etcNA1234I use appropriate language that is at the proper developmental/educational level for the patient and/or caregivers/family membersNA1234One way that I can improve is: Please complete  Competency: Work effectively with others as a member or leader of a health care team or other professional group.Knowledge/Skills/Attitudes Benchmarks:I takes the time to learn the names of othersNA1234I show respect to co-workers and I provide information when neededNA1234I facilitates team communication when in the role of team leaderNA1234I assume the role of consultant where appropriateNA1234I provides constructive verbal and written feedback to other members of the health care teamNA1234My medical records are thorough, readable, and done on timeNA Comments section. 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