Question

Based on the ACHE report on health administration leadership competency domains and assessment tool. Write an analysis/critique of its content. (Be sure to cover all five of the competency domains in this analysis.)

ACHE HEALTHCARE EXECUTIVE 2018 COMPETENCIES ASSESSMENT TOOL

The American College of Healthcare Executives Healthcare Executive Competencies Assessment Tool is offered as an instrument for healthcare executives to use in assessing their expertise in critical areas of healthcare management. We trust you will find this latest edition of the assessment tool useful.

The competencies are derived from job analysis surveys of healthcare executives across the healthcare continuum so that they are aligned with the challenges and work experienced by leaders today.* They represent knowledge needed to successfully perform as a healthcare manager regardless of the setting. ACHE updates the assessment annually. For your convenience, a complete list of ACHE resources, including readings, programs, assessments and self-study courses, are included in the back of the directory and referenced in each section.

The self-assessment is designed to help you identify areas of strength and areas you may wish to include in your personal development plan. You may choose to have your immediate supervisor use the tool to assess you and then compare results from your self-assessment with perceptions from your supervisor. Used in such a manner, the competency self- assessment can be a powerful tool in facilitating feedback about gaps in skills necessary for optimizing performance. Another way to use this assessment is to share the results with your mentor and work toward addressing identified professional growth areas.

Healthcare organizations also may choose to use this assessment tool to better define the requirements of specific roles within the organization. Once defined, the organization then can respond with a targeted training and development plan for those roles. Certain tasks also may require teams with a blend of strengths, and the self-assessment tool can be used to arrive at an ideal skill mix among such teams. The competency tool provides a common framework and lexicon for a variety of healthcare managers in a range of roles and settings; they serve to define the field. They can be used for individual as well as team self-assessment and improvement.

New this year is a sub-domain (under Business Skills and Knowledge) of Patient Safety, emphasizing competencies required and knowledge needed to address the core leadership challenges of achieving zero harm for both patients and the

workforce. While specific components of a patient safety and quality strategy will vary by organization, ACHE believes healthcare executives should lead a comprehensive approach to ensuring patient safety and quality. As supporting documents for this sub-domain, use Leading a Culture of Safety: A Blueprint for Success and Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human for understanding and advancing patient safety in your organization. These tools can be downloaded at ache.org/ Blueprint and npsf.org/freefromharm.

Within the Healthcare Executives Competency Assessment Tool, the competencies are categorized into five critical domains: Communication and Relationship Management, Leadership, Professionalism, Knowledge of the Healthcare Environment, and Business Skills and Knowledge. The definitions for the domains are as follows:

Communication and Relationship Management

1. Communication and Relationship

Management The ability to communicate clearly and concisely with internal and external customers, establish and maintain relationships, and facilitate constructive interactions with individuals and groups.

Communication and Relationship Management includes:

A. Relationship Management B. Communication Skills C. Facilitation and Negotiation

* The directory was derived from job analysis surveys conducted by Healthcare Leadership Alliance associations. In addition to the American College of Healthcare Executives, other members of the Healthcare Leadership Alliance are: American Association of Physician Leadership, American Organization of Nurse Executives, Healthcare Financial Management Association, Healthcare Information and Management Systems Society, and the Medical Group Management Association.

Professionalism

Leadership

Knowledge of the Healthcare Environment

Business Skills and Knowledge

*derived from HLA Model

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 1

2. Leadership The ability to inspire individual and organizational excellence, create a shared vision and successfully manage change to attain the organization’s strategic ends and successful performance. According to the HLA model, leadership intersects with each of the other four domains.

Leadership includes:

A. Leadership Skills and Behavior B. Organizational Climate and Culture C. Communicating Vision D. Managing Change

3. Professionalism The ability to align personal and organizational conduct with ethical and professional standards that include a responsibility to the patient and community, a service orientation, and a commitment to lifelong learning and improvement.

Professionalism includes:

A. Personal and Professional Accountability B. Professional Development and Lifelong Learning C. Contributions to the Community and Profession

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 2

4. Knowledge of the Healthcare Environment The understanding of the healthcare system and the environment in which healthcare managers and providers function.

Knowledge of the Healthcare Environment includes:

A. Healthcare Systems and Organizations B. Healthcare Personnel C. The Patient’s Perspective D. The Community and the Environment

5. Business Skills and Knowledge The ability to apply business principles, including systems thinking, to the healthcare environment.

Business Skills and Knowledge includes:

A. General Management B. Financial Management C. Human Resource Management D. Organizational Dynamics and Governance E. Strategic Planning and Marketing F. Information Management G. Risk Management H. Quality Improvement I. Patient Safety

Healthcare executives should demonstrate competence in aspects of all five domain areas. As you work your way through the self-assessment tool, we hope you will find it valuable and that it helps you along the path of lifelong professional education as you face the ongoing challenges of leadership. We have made it available as a PDF file at ache.org/CareerResources and hope you will share it with other healthcare executives.

COMPETENCY LEVEL Novice Competent Expert 1. Communication and Relationship Management

A. Relationship Management

Organizational structure and relationships 1 2 3 4 5

Build collaborative relationships 1 2 3 4 5

Demonstrate effective interpersonal relations 1 2 3 4 5

Develop and maintain medical staff relationships 1 2 3 4 5

Develop and maintain supplier relationships 1 2 3 4 5

Identify stakeholder needs/expectations 1 2 3 4 5

Provide internal customer service 1 2 3 4 5

Practice and value shared decision making 1 2 3 4 5

Other professional norms and standards of behaviors as defined by professions such as AHA, physician’s oaths and other professional pledges 1 2 3 4 5

Creating an ethical culture in an organization 1 2 3 4 5

Readings: 7, 10, 14, 15, 27, 50, 58, 65, 77, 82, 86, 95, 97, 98, 107, 112 Programs: 8, 11, 12, 14, 15, 18, 21, 35, 36, 38, 42, 46, 48, 58 Leadership Assessments: 1, 2, 6, 7 Self-Study Courses: 2, 3, 19

B. Communication Skills

Public relations 1 2 3 4 5

Principles of communication and their specific applications 1 2 3 4 5

Sensitivity to what is correct behavior when communicating with diverse cultures, internal and external 1 2 3 4 5

Communicate organizational mission, vision, objectives and priorities 1 2 3 4 5

Identify and use human and technical resources to develop and deliver communications 1 2 3 4 5

Prepare and deliver business communications, including meeting agendas, presentations, business reports and project communications plans 1 2 3 4 5

Present results of data analysis to decision makers 1 2 3 4 5

Provide and receive constructive feedback 1 2 3 4 5

Use factual data to produce and deliver credible and understandable reports 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 3

COMPETENCY LEVEL Novice Competent Expert Readings: 7, 21, 116 Programs: 12, 15, 35, 37, 45, 46, 56 Leadership Assessments: 7

C. Facilitation and Negotiation

Mediation, negotiation and dispute resolution techniques 1 2 3 4 5

Team building techniques 1 2 3 4 5

Labor relations strategies 1 2 3 4 5

Build effective physician and administrator leadership teams 1 2 3 4 5

Create, participate in and lead teams 1 2 3 4 5

Facilitate conflict and alternative dispute resolution 1 2 3 4 5

Facilitate group dynamics, process, meetings and discussions 1 2 3 4 5

Readings: 7, 10, 19, 24, 29, 61, 65, 66, 77, 79, 93, 95, 96, 106, 107, 112 Programs: 3, 15, 18, 35, 37, 42, 46, 58, 60 Leadership Assessments: 5, 7 Self-Study Courses: 2, 19, 20, 25

COMMUNICATION AND RELATIONSHIP MANAGEMENT DEVELOPMENT PLAN

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 4

COMPETENCY LEVEL Novice Competent Expert 2. LEADERSHIP

A. Leadership Skills and Behavior

Leadership styles/techniques 1 2 3 4 5

Leadership theory and situational applications 1 2 3 4 5

Potential impacts and consequences of decision making in situations both internal and external 1 2 3 4 5

Adhere to legal and regulatory standards 1 2 3 4 5

Champion solutions and encourage decision making 1 2 3 4 5

Develop external relationships 1 2 3 4 5

Collaborative techniques for engaging and working with physicians 1 2 3 4 5

Incorporate and apply management techniques and theories into leadership activities 1 2 3 4 5

Foster an environment of mutual trust 1 2 3 4 5

Support and mentor high-potential talent within the organization 1 2 3 4 5

Advocate and participate in healthcare policy initiatives 1 2 3 4 5

Readings: 3, 13, 17, 19, 24, 29, 30, 38, 41, 46, 50, 66, 68, 73, 74, 75, 78, 82, 95, 105, 106 Programs: 3, 13, 15, 18, 21, 30, 34, 37, 41, 42, 45, 46, 57, 58 Leadership Assessments: 1, 2, 4, 7 Self-Study Courses: 1, 3, 5, 7, 13, 20

B. Organizational Climate and Culture

Create an organizational climate that encourages teamwork 1 2 3 4 5

Create an organizational culture that values and supports diversity 1 2 3 4 5

Knowledge of own and others’ cultural norms 1 2 3 4 5

Assess the organization, including corporate values and culture, business processes and impact of systems on operations 1 2 3 4 5

Readings: 36, 74, 79, 85, 90, 98, 106 Programs: 2, 8, 16, 23, 31, 35, 46, 58 Leadership Assessments: 7 Other: 3

C. Communicating Vision

Establish a compelling organizational vision and goals 1 2 3 4 5

Create an organizational climate that facilitates individual motivation 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 5

COMPETENCY LEVEL Novice Competent Expert Encourage a high level of commitment to the purpose and values of the organization 1 2 3 4 5

Hold self and others accountable for organizational goal attainment 1 2 3 4 5

Gain physician buy-in to accept risk and support new business ventures 1 2 3 4 5

Readings: 10, 15, 19, 24, 29, 65, 66, 74, 77, 78, 79, 82, 106, 112, 123 Programs: 2, 8, 12, 13, 15, 18, 35, 36, 46 Leadership Assessments: 7 Self-Study Courses: 1, 13, 20

D. Managing Change

Promote and manage change 1 2 3 4 5

Explore opportunities for the growth and development of the organization on a continuous basis 1 2 3 4 5

Promote continuous organizational learning/improvement 1 2 3 4 5

Anticipate and plan strategies for overcoming obstacles 1 2 3 4 5

Anticipate the need for resources to carry out initiatives 1 2 3 4 5

Develop effective medical staff relationships in support of the organization’s mission, vision and strategic plan 1 2 3 4 5

Readings: 1, 2, 3, 7, 10, 14, 15, 19, 24, 28, 29, 43, 52, 58, 65, 74, 77, 78, 79, 82, 83, 85, 95, 96, 98, 102, 107, 112 Programs: 2, 11, 13, 18, 25, 27, 30, 34, 35, 36, 37, 38, 45, 46, 57, 58, 61 Leadership Assessments: 4, 6 Self-Study Courses: 2, 13, 19

LEADERSHIP DEVELOPMENT PLAN

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 6

COMPETENCY LEVEL Novice Competent Expert 3. PROFESSIONALISM

A. Personal and Professional Accountability

Patient rights and responsibilities 1 2 3 4 5

Ethics committee’s roles, structure and functions 1 2 3 4 5

Consequences of unethical actions 1 2 3 4 5

Organizational business and personal ethics 1 2 3 4 5

Cultural and spiritual diversity for patients and staff as they relate to healthcare needs 1 2 3 4 5

Conflict of interest situations as defined by organizational bylaws, policies and procedures 1 2 3 4 5

Professional roles, responsibility and accountability 1 2 3 4 5

Professional standards and codes of ethical behavior 1 2 3 4 5

Balance professional and personal pursuits 1 2 3 4 5

Uphold and act upon ethical and professional standards 1 2 3 4 5

Adhere to ethical business principles 1 2 3 4 5

Other professional norms and standards of behaviors as defined by professions such as AHA, physician’s oaths and other professional pledges 1 2 3 4 5

Creating an ethical culture in an organization 1 2 3 4 5

Readings: 27, 29, 58, 77, 88, 89, 120 Programs: 21, 34, 46, 48 Other: 1, 2, 4, 5, 6, 8

B. Professional Development and Lifelong Learning

Professional norms and behaviors 1 2 3 4 5

Professional societies and memberships 1 2 3 4 5

Contribute to professional knowledge and evidence 1 2 3 4 5

Time and stress management techniques 1 2 3 4 5

Conduct self-assessments 1 2 3 4 5

Network with colleagues 1 2 3 4 5

Participate in continuing education and career planning 1 2 3 4 5

Acquire and stay current with the professional body of knowledge 1 2 3 4 5

Readings: 23, 29, 81, 90, 118, 121 Programs: 8, 30, 33, 58 Leadership Assessments: 2, 3, 8 Self-Study Course: 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 7

COMPETENCY LEVEL Novice Competent Expert C. Contributions to the Community and Profession

Ethical implications of human subject research 1 2 3 4 5

Serve as the ethical guide for the organization 1 2 3 4 5

Practice due diligence to carry out fiduciary responsibilities 1 2 3 4 5

Mentor, advise and coach 1 2 3 4 5

Advocate for patients, families and communities 1 2 3 4 5

Advocate with physicians for the importance of hiring professionally trained and certified administrators and supporting their professional development 1 2 3 4 5

Participate in community service 1 2 3 4 5

Readings: 2, 38, 41, 66, 67, 89 Programs: 15, 26 Self-Study Courses: 1, 7, 20 Other: 7, 8

PROFESSIONALISM DEVELOPMENT PLAN

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 8

COMPETENCY LEVEL Novice Competent Expert 4. KNOWLEDGE OF THE HEALTHCARE ENVIRONMENT

A. Healthcare Systems and Organizations

Healthcare and medical terminology 1 2 3 4 5

Managed care models, structures and environment 1 2 3 4 5

The interdependency, integration and competition among healthcare sectors 1 2 3 4 5

Levels of healthcare along the continuum of care 1 2 3 4 5

Levels of service from a business perspective 1 2 3 4 5

Evidence-based management practice 1 2 3 4 5

Healthcare economics 1 2 3 4 5

Requirements for nonprofit healthcare organizations 1 2 3 4 5

The interrelationships among access, quality, cost, resource allocation, accountability and community 1 2 3 4 5

Readings: 1, 10, 16, 21, 28, 53, 54, 55, 94, 102, 108 Programs: 2, 8, 10, 29, 36, 55, 61

B. Healthcare Personnel

Ancillary services 1 2 3 4 5

Physician roles 1 2 3 4 5

The healthcare sectors 1 2 3 4 5

Staff perspective in organizational settings 1 2 3 4 5

Nurse and allied health professionals’ scope of practice 1 2 3 4 5

Support services 1 2 3 4 5

Role of nonclinical professionals in the healthcare system 1 2 3 4 5

Educational funding for healthcare personnel 1 2 3 4 5

Workforce issues 1 2 3 4 5

Readings: 11, 19, 32, 50, 56, 62, 66, 90, 106, 123 Programs: 11, 15, 29, 42, 48 Self-Study Courses: 3, 20

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 9

COMPETENCY LEVEL Novice Competent Expert C. The Patient’s Perspective

The patient’s perspective (e.g., cultural differences, expectations) 1 2 3 4 5

Readings: 2, 12, 101 Program: 28 Self-Study Course: 12

D. The Community and the Environment

Socioeconomic environment in which the organization functions 1 2 3 4 5

Healthcare trends 1 2 3 4 5

Implications of community standards of care 1 2 3 4 5

Healthcare technological research and advancements 1 2 3 4 5

Organization and delivery of healthcare 1 2 3 4 5

Community standards of care 1 2 3 4 5

Corporate compliance laws and regulations 1 2 3 4 5

Regulatory and administrative environment in which the organization functions 1 2 3 4 5

Governmental, regulatory, professional and accreditation agencies 1 2 3 4 5

Legislative issues and advocacy 1 2 3 4 5

Readings: 1, 13, 27, 39, 60, 73, 75, 102, 124 Programs: 26, 27, 36, 45, 61 Self-Study Course: 12 Other: 8

KNOWLEDGE OF THE HEALTHCARE ENVIRONMENT DEVELOPMENT PLAN

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 10

COMPETENCY LEVEL Novice Competent Expert 5. BUSINESS SKILLS AND KNOWLEDGE

A. General Management

Ability to analyze and evaluate information to support a decision or recommendation 1 2 3 4 5

Ability to distinguish relevant from irrelevant information 1 2 3 4 5

Ability to integrate information from various sources to make decisions or recommendations 1 2 3 4 5

Collect and analyze data from internal and external sources relevant to each situation 1 2 3 4 5

Basic business contracts 1 2 3 4 5

Techniques for business plan development, implementation and assessment 1 2 3 4 5

Justify a new business model or business plan 1 2 3 4 5

Principles of public affairs and community relations 1 2 3 4 5

The functions of organizational policies and procedures 1 2 3 4 5

Analyze the current way of doing business and clinical processes 1 2 3 4 5

Anticipate cause-and-effect relationships 1 2 3 4 5

Conduct needs analysis, identify and prioritize requirements 1 2 3 4 5

Define problems or opportunities 1 2 3 4 5

Distinguish between important and unimportant aspects of business and clinical situations as a basis for sound decision making 1 2 3 4 5

Identify alternate processes and potential solutions 1 2 3 4 5

Promote and apply problem-solving philosophies 1 2 3 4 5

Utilize comparative analysis strategies 1 2 3 4 5

Demonstrate critical thinking and analysis 1 2 3 4 5

Prioritize or triage as necessary to ensure critical functions are repaired, maintained or enhanced 1 2 3 4 5

Broad systems connections—potential impacts and consequences of decisions in a wide variety of situations both internal and external 1 2 3 4 5

Systems theory 1 2 3 4 5

Systems thinking 1 2 3 4 5

Champion systems thinking 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 11

COMPETENCY LEVEL Novice Competent Expert

Identify how a system design accommodates business processes 1 2 3 4 5

Seek information from a variety of sources 1 2 3 4 5

Evidence-based practice 1 2 3 4 5

Facilities planning 1 2 3 4 5

Inventory control systems 1 2 3 4 5

Project management 1 2 3 4 5

Purchasing procurement 1 2 3 4 5

Develop work plans 1 2 3 4 5

Perform audits of systems and operations 1 2 3 4 5

Management functions 1 2 3 4 5

Assess organizational perception of systems effectiveness and departmental effectiveness 1 2 3 4 5

Develop requests for information and requests for proposals 1 2 3 4 5

Manage vendor contracts 1 2 3 4 5

Measure quantitative dimensions of systems and departmental effectiveness 1 2 3 4 5

Organize and manage the human and physical resources of the organization to achieve input, buy-in and optimal performance 1 2 3 4 5

Readings: 10, 19, 24, 28, 33, 49, 53, 58, 62, 71, 72, 86, 93, 94, 98, 116, 117, 123 Programs: 9, 42, 44, 59 Leadership Assessments: 1, 3 Self-Study Courses: 4, 5, 9, 17, 21, 24

B. Financial Management

Basic accounting principles 1 2 3 4 5

Financial management and analysis principles 1 2 3 4 5

Financial planning methodologies 1 2 3 4 5

Financial statements 1 2 3 4 5

Outcomes measures and management 1 2 3 4 5

Reimbursement principles, ramifications and techniques, including rate setting and contracts 1 2 3 4 5

Principles of operating, project and capital budgeting 1 2 3 4 5

Fundamental productivity measures 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 12

COMPETENCY LEVEL Novice Competent Expert Financial controls and auditing principles 1 2 3 4 5

Revenue generation 1 2 3 4 5

Asset management, including depreciation schedule, facilities, equipment, etc. 1 2 3 4 5

Analyze financial reward versus risk 1 2 3 4 5

Apply financial planning methodologies to organizational objectives 1 2 3 4 5

Develop accounting and financial control systems 1 2 3 4 5

Develop and use performance monitoring metrics 1 2 3 4 5

Develop coding and reimbursement policies and procedures 1 2 3 4 5

Establish business relationships with financial advisors 1 2 3 4 5

Maintain compliance with tax laws and filing procedures 1 2 3 4 5

Negotiate third-party contracts 1 2 3 4 5

Provide stewardship of financial resources 1 2 3 4 5

Potential impacts and consequences of financial decision making on operations, healthcare, human resources and quality of care 1 2 3 4 5

Financing including funding sources, the process of obtaining credit and bond ratings, and issuing bonds 1 2 3 4 5

Philanthropy and foundation work, including source of funding for non-profit organizations or to target for-profit organizations’ activities 1 2 3 4 5

Supply chain systems, structures and processes 1 2 3 4 5

Readings: 6, 31, 33, 35, 36, 40, 44, 69, 85, 97, 114, 116, 122 Programs: 2, 3, 5, 6, 7, 14, 23, 24, 25, 42, 61 Self-Study Courses: 14, 21, 23, 24

C. Human Resource Management

Human resources laws and regulations 1 2 3 4 5

Performance management systems 1 2 3 4 5

Recruitment and retention techniques 1 2 3 4 5

Staffing methodologies and productivity management 1 2 3 4 5

Employee satisfaction measurement and improvement techniques 1 2 3 4 5

Employee motivational techniques 1 2 3 4 5

Compensation and benefits practices 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 13

COMPETENCY LEVEL Novice Competent Expert Worker safety, security and employee health issues 1 2 3 4 5

Conflict resolution and grievance procedures 1 2 3 4 5

Organizational policies and procedures and their functions 1 2 3 4 5

The need for and/or desirability of outsourcing 1 2 3 4 5

The varying work environments in which staff work 1 2 3 4 5

Define staff roles, responsibilities and job descriptions 1 2 3 4 5

Manage departmental personnel processes, including performance appraisals; incentives; staff recruitment, selection and retention; training and education; coaching and mentoring 1 2 3 4 5

Job classification systems 1 2 3 4 5

Develop and implement policies and procedures with physicians to address physician behavioral and burnout issues 1 2 3 4 5

Develop and manage employee performance management systems 1 2 3 4 5

Develop effective physician recruitment and retention programs 1 2 3 4 5

Develop employee benefit and assistance plans 1 2 3 4 5

Engage in workforce planning 1 2 3 4 5

Evaluate and manage employee efficiency and productivity 1 2 3 4 5

Potential impacts and consequences of human resources 1 2 3 4 5

Decision making on operations, finances, healthcare and quality of care 1 2 3 4 5

Selection techniques, including commonly available assessments and relative benefits 1 2 3 4 5

Labor relations practices and strategies 1 2 3 4 5

Job design processes 1 2 3 4 5

Succession planning models 1 2 3 4 5

Readings: 7, 10, 19, 24, 32, 33, 38, 41, 61, 62, 88, 107 Program: 15 Self-Study Courses: 1, 7, 19, 20

D. Organizational Dynamics and Governance

Organization systems theories and structures 1 2 3 4 5

How an organization’s culture impacts its effectiveness 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 14

COMPETENCY LEVEL Novice Competent Expert Governance theory 1 2 3 4 5

Governance structure 1 2 3 4 5

Medical staff structure and its relationship to the governing body and facility operation 1 2 3 4 5

Public policy matters and legislative and advocacy processes 1 2 3 4 5

Organizational dynamics, political realities and culture 1 2 3 4 5

Principles and practices of management and organizational behavior 1 2 3 4 5

Build trust and cooperation between/among stakeholders 1 2 3 4 5

Construct and maintain governance systems 1 2 3 4 5

Document and implement policies and procedures 1 2 3 4 5

Evaluate and improve governing bylaws, policies and processes 1 2 3 4 5

Facilitate physician understanding and acceptance of good business management 1 2 3 4 5

Manage the performance of subsystems in a manner that optimizes the whole synergy 1 2 3 4 5

Interpret and integrate federal, state and local laws and regulation 1 2 3 4 5

Readings: 19, 24, 29, 33, 46, 83, 92, 95, 96, 97, 107, 123 Programs: 1, 8, 15, 16, 34, 46 Self-Study Course: 20 Other: 8

E. Strategic Planning and Marketing

Business plan development and implementation process 1 2 3 4 5

Business planning, including business case and exit- strategy development 1 2 3 4 5

Evaluate whether a proposed solution aligns with the organizational business plan 1 2 3 4 5

Marketing principles and tools 1 2 3 4 5

Marketing plan development 1 2 3 4 5

Manage projects and/or resources 1 2 3 4 5

Healthcare system services 1 2 3 4 5

Implementation planning 1 2 3 4 5

Crisis and disaster planning 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 15

COMPETENCY LEVEL Novice Competent Expert Characteristics of strategic decision support 1 2 3 4 5

Strategic planning processes development and implementation 1 2 3 4 5

Develop and monitor departmental strategic and tactical objectives 1 2 3 4 5

Develop a benefits realization model that measures product or service performance to ensure that strategic goals are met 1 2 3 4 5

Organizational mission, vision, objectives and priorities 1 2 3 4 5

Plan for business continuance in the face of potential disasters that could disrupt service delivery 1 2 3 4 5

Pursuing and establishing partnerships and strategic alliances 1 2 3 4 5

Readings: 25, 33, 44, 48, 52, 61, 91, 92, 94, 102, 104, 106, 114, 115, 116, 117 Programs: 4, 10, 16, 23, 34, 36, 37, 46, 54, 57 Self-Study Courses: 8, 10, 11, 16

F. Information Management

Application software 1 2 3 4 5

Characteristics of administrative systems/programs 1 2 3 4 5

Characteristics of clinical systems/programs 1 2 3 4 5

Confidentiality principles and laws 1 2 3 4 5

Data analysis, including manipulation, understanding of and ability to explain data 1 2 3 4 5

Electronic education and information resources and systems 1 2 3 4 5

Health informatics 1 2 3 4 5

Information systems planning and implementation 1 2 3 4 5

Technology trends and clinical applications 1 2 3 4 5

Principles of database and file management 1 2 3 4 5

Technology privacy, confidentiality and security requirements 1 2 3 4 5

Role and function of information technology in operations 1 2 3 4 5

Testing and evaluation activities of IT systems 1 2 3 4 5

Information systems continuity 1 2 3 4 5

Analyze problem reports for trends 1 2 3 4 5

Conduct demonstrations, evaluate and select healthcare IT systems 1 2 3 4 5

Ensure accuracy and integrity of data 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 16

COMPETENCY LEVEL Novice Competent Expert Compatibility of software, hardware and network components to facilitate business operations 1 2 3 4 5

Ensure staff members are trained to use information systems 1 2 3 4 5

Evaluate results of a system security/privacy effectiveness assessment 1 2 3 4 5

Integrate IT systems that support decision making 1 2 3 4 5

Link the IT plan to the business plan 1 2 3 4 5

Monitor IT systems’ sustainability, reliability and maintainability 1 2 3 4 5

Monitor and adjust IT system capacity 1 2 3 4 5

Recommend policies and procedures for information management systems 1 2 3 4 5

Information systems continuity, including disaster planning, recovery, backup, security, sabotage and natural disasters 1 2 3 4 5

Factors that influence selection, acquisition, and maintenance of IT systems, including upgrades and conversions, and technology lifecycles 1 2 3 4 5

Healthcare analytics 1 2 3 4 5

Readings: 28, 33, 40, 49 Programs: 9, 21, 59

G. Risk Management

Risk management principles and programs 1 2 3 4 5

Confidentiality principles and laws 1 2 3 4 5

Corporate compliance laws and regulations 1 2 3 4 5

Medicare/Medicaid/third-party payment regulations 1 2 3 4 5

Inspection and accrediting standards, regulations and organizations 1 2 3 4 5

Patients’ rights, laws and regulations 1 2 3 4 5

Compliance with regulatory agencies and tax status requirements 1 2 3 4 5

Contingency planning 1 2 3 4 5

Corporate history and record-keeping procedures 1 2 3 4 5

Credentialing, medical malpractice and professional liability 1 2 3 4 5

Personnel and property security plans and policies 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 17

COMPETENCY LEVEL Novice Competent Expert Professional resource networks for risk-related activities 1 2 3 4 5

Risk assessments and analyses 1 2 3 4 5

Risk mitigation 1 2 3 4 5

Risks related to personnel management 1 2 3 4 5

Risks related to quality management and patient safety 1 2 3 4 5

Conflict resolution and grievance procedures 1 2 3 4 5

Establish patient, staff and organizational confidentiality policies 1 2 3 4 5

Maintain compliance with government contractual mandates 1 2 3 4 5

Plan for business continuance in the face of potential disasters that could disrupt service delivery 1 2 3 4 5

Readings: 3, 13, 57, 62, 72, 73, 102, 110, 111 Programs: 36, 61 Self-Study Courses: 4, 11, 17

H. Quality Improvement

Benchmarking techniques 1 2 3 4 5

Medical staff peer review 1 2 3 4 5

Clinical methodologies 1 2 3 4 5

Utilization review and management regulations 1 2 3 4 5

Clinical pathways and disease management 1 2 3 4 5

National quality initiatives, including patient safety 1 2 3 4 5

Knowledge of tools for improving patient safety 1 2 3 4 5

Customer satisfaction principles and tools 1 2 3 4 5

Data collection, measurement and analysis tools and techniques 1 2 3 4 5

Patient communication systems 1 2 3 4 5

Quality improvement theories and frameworks 1 2 3 4 5

Quality planning and management 1 2 3 4 5

Recognition of quality as a strategic initiative 1 2 3 4 5

Training and certification 1 2 3 4 5

Develop and implement performance and process improvement programs 1 2 3 4 5

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 18

COMPETENCY LEVEL Novice Competent Expert Develop and implement quality assurance and patient satisfaction programs 1 2 3 4 5

Develop clinical pathway structure and function 1 2 3 4 5

Readings: 2, 4, 5, 16, 33, 37, 51, 67, 70, 76, 80, 100, 101, 102, 103, 111, 119 Programs: 2, 6, 9, 37, 42, 56, 61 Self-Study Courses: 6, 10

BUSINESS SKILLS AND KNOWLEDGE DEVELOPMENT PLAN

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 19

COMPETENCY LEVEL Novice Competent Expert I. Patient Safety*

Establish and sustain a safety culture 1 2 3 4 5

Collaborate with public agencies and private organizations to support patient safety 1 2 3 4 5

Create a common set of safety metrics that reflect meaningful outcomes 1 2 3 4 5

Funding for research in patient safety and implementation science 1 2 3 4 5

Address patient safety across the care continuum 1 2 3 4 5

Support the healthcare workforce by providing a safe and healthy work environment to optimize safe patient care 1 2 3 4 5

Partner with patients and families for the safest care 1 2 3 4 5

Ensure that technology is secure and optimized to improve patient safety 1 2 3 4 5

*These competencies were adapted from original source material from the Institute for Healthcare Improvement at www.IHI.org with its permission, ©NPSF 2015.

Readings: 59, 111 Programs: 59 Other: 9, 10

PATIENT SAFETY DEVELOPMENT PLAN

ACHE Healthcare Executive Competencies Assessment Tool Copyright © 2018 by the Healthcare Leadership Alliance and the American College of Healthcare Executives 20

Answer 1

The present medicinal services administrators and pioneers must have administration ability sufficiently modern to coordinate the expanded multifaceted nature of the human services condition. Officials are required to show quantifiable results and adequacy and to rehearse confirm based administration. In the meantime, scholarly and proficient projects are underscoring the accomplishment of skills identified with working environment adequacy. The move to confirm based administration has prompted various endeavors to characterize the capabilities most fitting for social insurance. The Healthcare Management Coalition, a consortium of 6 noteworthy expert enrollment associations, utilized the exploration from and involvement with their individual credentialing procedures to place five competency areas basic among all honing social insurance administrators:

-correspondence and relationship administration,

-polished methodology,

-authority,

-information of the medicinal services framework, and

-business abilities and learning.

The HLA occupied with a formal procedure to portray the information, aptitudes, and capacities inside every area and to figure out which of these skills were center or normal among the enrollment of all HLA affiliations and which were forte or particular to the individuals from at least one HLA associations. This procedure created huge competency articulations, which were then sorted out into the Competency Directory, an interesting and intelligent database that can be utilized for surveying individual and authoritative abilities. In general, this work brings together the arena of humanoid services administration and gives a vocabulary and a reason for coordinated effort among various kinds of social insurance administrators. This talks about the means that the HLA took after. It additionally shows the HLA Capability Almanac; its request and pertinence to the specialist and scholarly networks; and its qualities, constraints, and potential.

The authority US government site for occupations has a great amount of chances identified with several callings for scholarly majors offered in advanced education. In the audit for this section, it was especially evident that what numerous college‐based authority programs consider that administration aptitudes are exceedingly respected skills esteemed by government offices. As per the Assembly for the Progression of Values in Higher Education, foundations of advanced education ought to give functional encounters, for example, how to run a compelling gathering and overseeing spending plans through authority improvement programs. Some initiative improvement programs have moved far from showing administration abilities and that pattern might put understudies off guard in the aggressive working environment.

From the general abilities to more particular expert authority results, we urge administration teachers to think about the setting of their establishment when arranging besides assessing informative exposed entrances for substitutes.