Career Development Planning Document
Self-Assessment Form for Chair Chiefs

Faculty Information
Faculty/Member Name:	Click here to enter text.
Academic Rank:	Choose an item.
Primary Appointment:	Click here to enter text.
Cross Appointments:	Click here to enter text.
Department / Division:	Click here to enter text.
Effective Dates
Effective Date:	Review Period:
Click here to enter a date.	From:	Click here to enter a date.	To:	Click here to enter a date.
Date of First Appointment:	Last CDP Meeting:
Click here to enter a date.	On:	Click here to enter a date.	Years:	Click here to enter text.
Academic Role Category Information
Academic Role Category:	Please Select
"Please add the percentages from your personal ARC, previously signed by yourself"
Clinical:	Click here to enter text.
Teaching:	Click here to enter text.
Research:	Click here to enter text.
Administration:	Click here to enter text.
Health Care Leadership / Role Model / General:	Click here to enter text.
Total:	Click here to enter text.

Total must = 100% or the form will be sent back.

SECTION A - Academic Role Category
For each category, please see the attached Academic Role Category (ARC) for general expectations. Please describe your actual activity and note any variance relative to the ARC description
Clinical:	Click here to enter text.
Teaching:	Click here to enter text.
Research:	Click here to enter text.
Administration:	Click here to enter text.
Health Care Leadership / Role Model / General:	Click here to enter text.
Notes:	Click here to enter text.
Goals for Upcoming Year:	Click here to enter text.

SECTION A - Academic Role Category – Workload Distribution Changes
"Will the ARC or the Workload Distribution change for the coming year?"
If Yes, the new ARC should be: Click here to enter text.	Please Select
If Yes, Please Explain Below:	If No, Please continue to Section B: Mentoring
Click here to enter text.

SECTION B - Mentoring
Mentoring Meeting Dates
Click here to enter a date.	Click here to enter a date.	Click here to enter a date.
Click here to enter a date.	Click here to enter a date.	Click here to enter a date.
Click here to enter a date.	Click here to enter a date.	Click here to enter a date.
Click here to enter a date.	Click here to enter a date.	Click here to enter a date.
Next Mentoring Meeting Date:	Click here to enter a date.
Mentoring Committee Members:
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Mentoring Highlights
Note: Individuals may wish to note accomplishments or discussions for this period: (This section is Optional)
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SECTION C – Competencies
"Competencies are described as knowledge, skills or behaviours that are essential to the role of Physician, Dentist or Midwife. Please check the appropriate box below on each section and provide evidence where appropriate in the notes section."
1. Self-Awareness and Emotional Intelligence: "Consistently displays a caring, supportive attitude towards patients, staff, colleagues and leaders." Develop and maintain a sense of presence and emotional maturity. An accurate awareness of one's strengths and limitations. An understanding of one's own emotions and the impact of one's behaviour on others. Consistent behaviour that is congruent with personal and organizational values. Appropriate management of emotions. Demonstration of resilience in a range of complex and demanding situations. An inner confidence that one can succeed and overcome obstacles. Faculty Self Evaluation Collaborative Evaluation (To be filled out before the meeting) (To be filled out during the meeting) Taking all of these statements into account, please click on the appropriate sentence. (Only one) Taking all of these statements into account, please click on the appropriate sentence. (Only one - mutually agreed)
Notes:
Click here to enter text.

SECTION C – Competencies
"Competencies are described as knowledge, skills or behaviours that are essential to the role of Physician, Dentist or Midwife. Please check the appropriate box below on each section and provide evidence where appropriate in the notes section."

2. Development of Self and Others:

"Effective leaders are self-aware and have the ability to model honesty, integrity, resilience, and confidence. They seek opportunities for personal/learning and growth and expect the best from themselves while maintaining a work life balance. Effective leaders will help improve the skills and capabilities of others and foster long-term learning and development."

"Consistently demonstrates effective teaching skills to enhance the skills and knowledge of learners: (residents, medical students, fellows, clerks, peers, other health professionals)"

Is aware of own assumptions, values, principles, strengths, and limitations.

Models honesty, integrity, resilience, and confidence.

Effectively manages their own performance and work life balance/wellness.

Seeks opportunities and challenges for personal learning, growth, and character building, actively pursuing learning, knowledge, skills and self-development opportunities.

Advances the body of knowledge to the broader community.

Helps to improve the skills and capabilities of others and fosters their long term learning and development through performance management, coaching and mentoring leading to empowerment.

Uses learning and development to challenge others to actualize the core values of the healthcare system and achieve higher goals.

Expects the best from themselves and others: supports this expectation by setting high standards of excellence, clarifying roles and responsibilities, providing clear directions and priorities, monitoring achievement, providing feedback, taking action when poor performance does not improve, and celebrating progress and achievement.

Foster an environment for continuous learning and research.

Recognize accomplishments and achievements.

Pursue learning and self development opportunities: participate in leadership development opportunities.

Helps to improve the skills and capabilities of others through orientation and on-going performance feedback and development.

Oversee and monitor the Career Development and Planning (CDP) process regularly following guidelines approved by the Hospital(s) and University.

Engage in activities with colleagues to share learning.

Identify and mentor emerging leaders.

Faculty Self Evaluation	Collaborative Evaluation
(To be filled out before the meeting)	(To be filled out during the meeting)
Taking all of these statements into account, please click on the appropriate sentence. (Only one) Taking all of these statements into account, please click on the appropriate sentence. (Only one - mutually agreed)

Notes:
Click here to enter text.

SECTION C – Competencies
"Competencies are described as knowledge, skills or behaviours that are essential to the role of Physician, Dentist or Midwife. Please check the appropriate box below on each section and provide evidence where appropriate in the notes section."
3. Communicate and Engage Effectively: "Communicates appropriately: (patients, families, clinical team, learners, members, and other care providers)" Shows tact and diplomacy in dealing with others. Actively listens. Gives and receives feedback. Uses active listening when interacting with individuals or groups, reflecting on verbal and non-verbal behaviour in order to understand and respond appropriately to the concerns of others. Keeps others informed about issues that may affect them. Presents appropriate information clearly and concisely to a variety of audiences. Encourages open exchange of information and ideas using appropriate communications media. Ensures that all Department members are cognizant of the relevant policies and procedures of the hospital (s) in which they function. Give direction and leadership to the activities carried out by the Hospital Departments. Participate as appropriate in the overall initiatives and concerns of the hospital(s) and Schulich School of Medicine and Dentistry (Chair). Ensures effective communication pathways are maintained between the hospital(s) and Department members. Disseminate valuable knowledge to the broader community. Ensure all department members have a clear understanding of expectations related to academic responsibilities.
Faculty Self Evaluation Collaborative Evaluation (To be filled out before the meeting) (To be filled out during the meeting) Taking all of these statements into account, please click on the appropriate sentence. (Only one) Taking all of these statements into account, please click on the appropriate sentence. (Only one - mutually agreed)
Notes:
Click here to enter text.

SECTION C – Competencies
"Competencies are described as knowledge, skills or behaviours that are essential to the role of Physician, Dentist or Midwife. Please check the appropriate box below on each section and provide evidence where appropriate in the notes section."
4. Build Collaborative Relationships, Coalitions and Strategic Partnerships: Develops and maintains positive working relationships. Create connections, trust, and shared meaning with individuals and groups to achieve the organization's objectives and to improve the health of others. Facilitates environments of collaboration and cooperation to achieve results and to achieve the vision. Navigates effectively through individuals, teams and organizations to achieve strategic results for the maximum benefit. Participates in a team approach to care, education and research within the health centres, faculty and community. Builds the organization's capability to produce and sustain results. Builds/encourages strategic partnerships with eternal agencies to support care, education and research. Promotes community involvement in order to foster long term partnerships that help achieve an integrated health care system. Develops and fosters, in departmental members, coordination and cooperative relationships with the Department and within the hospital(s). Plays a role in provincial and regional processes as they relate to specific Hospital Departmental services. Faculty Self Evaluation Collaborative Evaluation (To be filled out before the meeting) (To be filled out during the meeting) Taking all of these statements into account, please click on the appropriate sentence. (Only one) Taking all of these statements into account, please click on the appropriate sentence. (Only one - mutually agreed)
Notes:
Click here to enter text.

SECTION C – Competencies
"Competencies are described as knowledge, skills or behaviours that are essential to the role of Physician, Dentist or Midwife. Please check the appropriate box below on each section and provide evidence where appropriate in the notes section."
5. lnspire, Achieve, and Innovate: "Inspiration, achievement and innovation can only be grown when there are conditions that foster a forum for sharing the open exchange of ideas to establish a vision, to encourage innovation or quality improvement and to support others in achieving their goals. Contributes to continual improvement in quality of care:" Demonstrates a desire to provide quality, patient-centered care by focusing efforts on discovering the expressed and unexpressed needs of customers, patients and stakeholders, and meeting these needs. Integrates organizational missions, values and reliable, valid evidence to make decisions. Considers innovations by challenging the way or the status quo. Addresses barriers to the growth and implementation of innovative ideas. Creates a climate of continuous improvement and creativity aimed at systemic change. Employs methods to gather expertise, knowledge and skills to encourage open exchange of information, and use quality evidence to influence action across the system. Establishes the vision, mission, objectives and priorities for the department in alignment with the health centres and faculty. Plans and implements strategic priorities for care delivery, education and research. Effectively assess system-wide opportunities and risks in setting course of action for the University and Hospital Department. Faculty Self Evaluation Collaborative Evaluation (To be filled out before the meeting) (To be filled out during the meeting) Taking all of these statements into account, please click on the appropriate sentence. (Only one) Taking all of these statements into account, please click on the appropriate sentence. (Only one - mutually agreed)
Notes:
Click here to enter text.

SECTION C – Competencies
"Competencies are described as knowledge, skills or behaviours that are essential to the role of Physician, Dentist or Midwife. Please check the appropriate box below on each section and provide evidence where appropriate in the notes section."
6. Transform and lead to the Future: "Demonstrates core competencies in transformational leadership" Maintains work effectiveness in uncertain and new situations. Treats error as opportunities to learn and to improve performance care practices and the health care system. Actively contributes to change processes that improve health service delivery. Considers and incorporates into any change strategy the impact of actions/ change to patients, family members, employees, colleagues and others. Uses their understanding to influence the political process positively. Understands the politics of their hospital (i.e. how decisions are made and who makes them). Seeks outside the organization for new and innovative ways to conduct research, lead learning, provide care and transform the health care system. Leads others in change by collaboratively setting priorities, determining methods and procedures, and implementing continuous improvement strategies. Leads change processes by providing vision a plan, motivation, skills, and resources. Promotes and maintains the mission, goals and objectives of the hospital (s). Promotes and improves the standards of patient care, service teaching and research on behalf of the hospital (s). Encourages, advises, and oversees both University and Hospital based research by members of the Hospital Department subject to University and Hospital policies regarding research activities. Ensure the views, knowledge and opinions of the professional staff/clinical faculty are heard in corporate initiatives by supporting involvement in corporate committees, working groups and implementation strategies. Models an ability to deal with uncertainty and adapt to ongoing change. Constructively challenge the status quo.
Faculty Self Evaluation Collaborative Evaluation (To be filled out before the meeting) (To be filled out during the meeting) Taking all of these statements into account, please click on the appropriate sentence. (Only one) Taking all of these statements into account, please click on the appropriate sentence. (Only one - mutually agreed)
Notes:
Click here to enter text.

SECTION C – Competencies
"Competencies are described as knowledge, skills or behaviours that are essential to the role of Physician, Dentist or Midwife. Please check the appropriate box below on each section and provide evidence where appropriate in the notes section."
7. Manage Resources: "In order for clinicians to be effective in a complex system of work it requires that clinicians be aware of how resources are acquired, managed, requested, utilized and evaluated. Resources can include human, financial, and physical resources. Consistently manages and uses resources efficiently and effectively. " Monitors/evaluates ongoing use of resources in meeting established goals. Holds self accountable for results achieved against individual performance; corrects the course as appropriate. Understands that meeting goals will require working collaboratively and sharing resources. Establishes strategic goals, outcomes to achieve, and standards to measure accomplishments; develops mechanisms of accountability. Actively advocates in resource allocation decisions to meet established goals and objectives including departmental space and academic and clinical resources to ensure the department’s mission can be carried out. Develops and integrates financial awareness into planning, decision making, performance assessment, and evaluation. Participates with others to define strategies for approved resource use and growth negotiating system-wide trade-offs to responsibly meet established goals and objectives within limitations of scarce resources. Facilitates change in a collaborative way to meet the established goals and allow for sharing of resources. Advocates for and wisely manages resources from the University, Hospital, Ministry of Health or other programmatic funding as appropriate, including money, people, technology, materials, space support and time to create and sustain conditions for quality delivery of health care. Builds awareness of issues and outcomes as they affect the organization's and stakeholders' strategic direction. Understands the business implications of opportunities to drive decisions when implementing business strategies. Takes responsibility (to the hospital and the University) for the type, level, and quality of medical care given by all members in the various categories of Staff within the Department. Has authority to advise on, or intervene in, the management of any Hospital patient under the care of a member of the Hospital Department with the support of the Site Chief &/or Division Chiefs. Develops and monitors a physician human resource needs and plans, in order to ensure that the clinical, educational and research mission of the department can be carried out. Provides evidence to support appropriate physician manpower. Participates in Financial Management committees of the Department. Actively participates in collaboration with the University and the Hospital Foundations in development. Directs the Hospital(s) and University department human resource planning, recruitment, selection, credentialing, assignment, Career Development and Planning Process, professional appraisal and disciplinary functions in accordance with Hospital and University regulations. Ensures appropriate divisional and/or onsite management and coverage where appropriate. Takes responsibility for the provision and supervision of Hospital Department activities related to planning, policy and the management of medical affairs in accordance with the Medical Staff By-Laws and the Hospital Rules and Regulations. Shares responsibility with the academic Chair for the management of the funding envelope assigned to the Department by the Hospital(s). Shares responsibility for the management of capital and operating resources assigned by the Hospital(s) to the Departments. Provides recommendations on University and Hospital remuneration. Provides recommendations to the Dean regarding the appointment, reappointment and promotion of their department’s faculty members. Determines the leadership structure for the University and Hospital Department and selects leaders based on an open and transparent process to ensure appropriate management at each site and/or in each Division of the Department in London and its distributed sites.
Faculty Self Evaluation Collaborative Evaluation (To be filled out before the meeting) (To be filled out during the meeting) Taking all of these statements into account, please click on the appropriate sentence. (Only one) Taking all of these statements into account, please click on the appropriate sentence. (Only one - mutually agreed)
Notes:
Click here to enter text.

SECTION D - Signatures
“Please share any other thoughts, comments or requests in this section. Sign and date when completed. Please submit the original signed copy to the departments administration office following your CDP meeting.”
Comments:	Click here to enter text.
Short Term Goals For Role Category and/or Competency Development:	Click here to enter text.
Long Term Goals For Role Category and/or Competency Development:	Click here to enter text.
Assistance Needed:	Click here to enter text.
Agreements / Discussions Arising from the meeting:	Click here to enter text.

Signatures:	(Required)

Professional Staff/Clinical Faculty	Professional Leader	Professional Leader
Date	Date	Date