360-DEGREE EVALUATION FORM

SELF-ASSESSMENT

For use by: Residents and Students

INTERPERSONAL AND COMMUNICATION SKILLS

Background Information

The University of Maryland School of Medicine, Primary Care Education Initiative is piloting a 360-degree assessment system for residents and students.  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/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 final report for you.  Anonymity for those completing the report ensures that ratings and comments are fair as well as skill and behavior – based.

Five to ten individuals representative of the groups in the above diagram should be selected to complete a similar form regarding your progress.  You and your immediate supervisor should have input regarding who will complete these forms. 

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 Providing Useful Feedback

Not Applicable

Rarely demonstrates (<25% of the time)

Sometimes demonstrates (25-50% of the time)

Demonstrates in most cases (50-75% of the time)

Demonstrates in majority of cases (>75% of time)

· Use the full range of the rating scale. Use “Demonstrates in majority of cases” if you perceive that you engage in the behavior  >75% of the time.  Likewise with “1” – use it only if you engage in the behavior less than 25% of the time. 

· Use N/A if you don’t feel that you can provide a score.

· If you give yourself a score of either “Rarely demonstrates” or “Demonstrates in majority of cases” (the lowest or highest possible), please write in a comment for that question in the comments area that follows that section.

· Go by your own observations of your behavior, not by what you've possibly learned from other people.

Tips for Giving Useful Written Comments

· Useful comments give examples of specific behaviors. For example: "I'm 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 I’m with a patient I sometimes feel that I’m not really listening because I’m so worried about how far behind I’m 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-degree process is largely dependent on you and others being thoughtful, candid and, where appropriate, constructively critical.

Adapted in part from RE Brown & Associates, El Cerrito, California