360-DEGREE EVALUATION FORM - Dr. Angela Chmielewski

This process provides a full-circle view of resident/student skills and abilities by gathering information from various perspectives: the individual and others (peers, supervisors, patients, health care team members). This profile provides a more balanced overview than self-evaluation or peer/supervisor review.
The completed questionnaires will be compiled into a formal report for the Fellow.
Please rate the individual based on your recent experience with him/her. 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).

Evaluate where a "5" identifies an average, competent Palliative Medicine Physician who is in practice and out of training
Name: 


A red asterisk (*) indicates required questions.

  1. Patient and Family Care:
    Gathers accurate & critical information from all pertinent sources.*
    1 2 3 4 5   N/A
     


  1. Patient and Family Care:
    Care shows attention to age gender, sexual orientation,
    culture, disability*
    1 2 3 4 5   N/A
     


  1. Patient and Family:
    Care is based on 1) patient & family preference 2) best evidence
    3) clinical judgment*
    1 2 3 4 5   N/A
     


  1. Patient and Family Care:
    Collaborates with team to negotiate, implement and document care plan*
    1 2 3 4 5   N/A
     


  1. Patient and Family Care:
    Pain and symptoms are adequately assessed and timely managed.*
    1 2 3 4 5   N/A
     


  1. Patient and Family Care:
    Evaluate function, patient/family coping, practical, cultural and spiritual elements.*
    1 2 3 4 5   N/A
     


  1. Patient and Family Care:
    Comments:


  1. Medical Knowledge:
    Critically evaluates and explains best evidence.*
    1 2 3 4 5   N/A
     


  1. Medical Knowledge:
    Analyzes complex relationships and proposes unified systematic approach.*
    1 2 3 4 5   N/A
     


  1. Medical Knowledge:
    Identifies local and regional resources for informing & supporting patients/family.*
    1 2 3 4 5   N/A
     


  1. Medical Knowledge:
    Explains evidence-based best practice for palliative care.*
    1 2 3 4 5   N/A
     


  1. Medical Knowledge:
    Accurately characterizes family dynamics, coping strategies.*
    1 2 3 4 5   N/A
     


  1. Medical Knowledge:
    Comments:


  1. Practice Based Learning and Improvement:
    Uses library, internet and colleagues to efficiently manage information.*
    1 2 3 4 5   N/A
     


  1. Practice Based Learning and Improvement:
    Locates, critically reviews and applies scientific evidence and medical literature.*
    1 2 3 4 5   N/A
     


  1. Practice Based Learning and Improvement:
    Expresses importance and demonstrates habits for life-long learning.*
    1 2 3 4 5   N/A
     


  1. Practice Based Learning and Improvement:
    Reflects and grows from positive & negative clinical encounters.*
    1 2 3 4 5   N/A
     


  1. Practice Based Learning and Improvement:
    Maintains personal, physical, and mental health.*
    1 2 3 4 5   N/A
     


  1. Practice Based Learning and Improvement:
    Comments:


  1. Communication and Interpersonal Skills:
    Effective verbal, nonverbal & written communication to patients and families.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Effective verbal, nonverbal & written communication to team members.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Effective verbal, nonverbal & written communication to referring physicians.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Patient relationships are therapeutic, ethical, patient/family-centered.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Balances inquiry with advocacy.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Maintains comprehensive, timely and legible medical records.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Provides timely signatures for medico-legal documents and prescriptions.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Effectively facilitates family meetings when there is strong emotion and conflict.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Uses age-appropriate interventions to counsel patients/families.*
    1 2 3 4 5   N/A
     


  1. Communication and Interpersonal Skills:
    Comments:


  1. Professionalism:
    Prioritizes needs of patients/family/team members above self-interest.*
    1 2 3 4 5   N/A
     


  1. Professionalism:
    Assesses personal behavior and accepts responsibility for errors.*
    1 2 3 4 5   N/A
     


  1. Professionalism:
    Available & responsive to requests for assistance; provides timely follow-up.*
    1 2 3 4 5   N/A
     


  1. Professionalism:
    Behavior is ethical & honest as judged by AMA ethical principles.*
    1 2 3 4 5   N/A
     


  1. Professionalism:
    Honors & respects patients, families, and colleagues; maintains confidentiality.*
    1 2 3 4 5   N/A
     


  1. Professionalism:
    Comments:


  1. Systems Based Practice:
    Care represents cost effective best practices.*
    1 2 3 4 5   N/A
     


  1. Systems Based Practice:
    Evaluates and implements systems-improvement based on clinical practice data.*
    1 2 3 4 5   N/A
     


  1. Systems Based Practice:
    Integrates knowledge of health care system in developing the plan of care.*
    1 2 3 4 5   N/A
     


  1. Systems Based Practice:
    Comments:*


  1. Overall Clinical Competence:
    Please give an overall score.*
    1 2 3 4 5   N/A
     


  1. Overal Competence Comments:





Abbe Leffel
IL