Perioperative TeamworkAward

Criteria and Nomination

A perioperative nursing team who has demonstrated outstanding achievements in perioperative leadership by applying the theory of teamwork to their perioperative practice. One of the team members MUST be a NSW OTA member.

COMPULSORY CRITERIA:
Customer Focus / How the nominees value the needs of the organisation and the team.
Continuous Improvement / Describe the ways in which the nominees have monitored their performance as a team.
Outcomes / Describe the outcomes the nominees have achieved as a team that would not have been possible as individuals.
Striving for Best Practice / Describe how the nominees have benchmarked the teams achievements.
Leadership / Describe how the nominees have developed their team relationships.
Describe how the nominees have supported the direction of their teamwork to achieve their outcomes.
OPTIONAL CRITERIA:
Innovation / Describe the team approach the nominees have taken to achieving the organisation’s outcomes.
Application to other settings / Describe the ways in which the nominees have or plan to share their approach with other nursing/healthcare settings to improve patient outcomes.

Application process must be completed below and provided as per OTA Perioperative Awards Policy

Checklist – Member nominating please complete white areas
  • Name and zone of the full financial member of the Association who is proposing the nomination

Print name………………………………………………………. Zone: ………….…
Signed……………………………………………………….... Date…………….…
NSW OTA Honorary Secretary complete:
Received on: ……………….. Correct NSW OTA nomination form Yes

Comprehensive curriculum vitae is attached Yes Proceed to panel assessment Yes No
Comments:…………………………………………………………………………………………………………………..……..
Print name…………………………………………………….Signed……………………………………….. Date…………
NSW OTA Assessment panel complete Received on: …………………
Nominee fulfils all the criteria in the application form Yes Endorsed /Not Endorsed
Print name…………………………………………………….Signed……………………………………….. Date…………

The following criteria must be addressed in the body of the submission to assist the selection committee in assessing the candidate’s eligibility for the above award:

Perioperative TeamworkAward Nomination Details of the nominated Team leader (OTA member)
  • Surname
/
  • Other names

  • Postal address and postcode

  • Phone numbers
/ Home: Mobile:
  • Email address
/
  • Member of zone

Other team members:

  • Surname / Other names
/
  • Role

  • Surname / Other names
/
  • Role

  • Surname / Other names
/
  • Role

  • Surname / Other names
/
  • Role

  • Surname / Other names
/
  • Role

Please provide evidence (in ALL of the COMPULSORY white sections below) outlining the accomplishments of the person you are nominating which demonstrate they fulfil the criteria.

(attach additional page/s or expand boxes below if more space is required).

  • PROVIDE Customer Focusevidence:(COMPULSORY)
  • Describe how the nominees value the needs of the organisation and the team.

  • ……………………………………………………………………………………………………………………………..…….
  • …………………………………………………………………………………………………………………….……………...
  • …………………………………………………………………………………………………………………….……………..
  • …………………………………………………………………………………………………………………….……………..

  • PROVIDE Continuous Improvement evidence(COMPULSORY)
Describe the ways in which the nominees have monitored their performance as a team.
  • ………………………………………………………………………………………………………………………………….….
  • …………………………………………………………………………………………………………………….………….….
  • …………………………………………………………………………………………………………………….……………….
  • ……………………………………………………………………………………………………………………………….…….

  • PROVIDE Outcomes evidence(COMPULSORY)
Describe the outcomes the nominees have achieved as a team that would not have been possible as individuals.
……………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………..…….
……………………………………………………………………………………………………………………………….…….
……………………………………………………………………………………………………………………………….…….
  • PROVIDE Striving for Best Practice evidence(COMPULSORY)
Describe how the nominees have benchmarked their team achievements.
…………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
  • …………………………………………………………………………………………………………………….…….

  • PROVIDE Leadership evidence (COMPULSORY)
Describe how the nominees have developed their team relationships.
Describe how the nominees have supported the direction of their teamwork to achieve their outcomes.
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………..….
……………………………………………………………………………………………………………………………………….
  • …………………………………………………………………………………………………………………….…………….….

PROVIDE Innovation evidence (OPTIONAL)
Describe the team approach the nominees have taken to achieving the organisation’s outcomes.
……………………………………………………………………………………………………………………………….…….
……………………………………………………………………………………………………………………………….…….
……………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………….
  • PROVIDE Application to other settings evidence (OPTIONAL)
Describe the ways in which the nominees have or plan to share their approach with other nursing/healthcare settings to improve patient outcomes.
…………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….

Mail this form to the: NSW OTA Secretariat, PO Box 212, Croydon NSW 2132

OR fax to: (02) 97991867 OR email to:

NSW OTA Inc Perioperative Teamwork award– Criteria and Nomination Page 1 of 4

Updated and approved by NSW OTA Executive Committee Oct 2016