HEALTHCARE_LEADERSHIP_COMPETENCIES

		Healthcare Leadership Competencies Assessment
NAME

LAST 4 OF SSN

DATE

	I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
Proficiency Scale:	1 = No Experience 2 = Need Training 3 = Able to perform with supervision 4 = Able to perform independently

Rating Stars (Click)	RELATIONSHIP MANAGEMENT		1	2	3	4
0	Organizational structure and relationship
0	Build collaborative relationships
0	Develop and maintain medical staff relationships
0	Provide internal customer service
0	Practice and value shared decision making
Rating Stars (Click)	COMMUNICATION SKILLS		1	2	3	4
0	Sensitive to what is correct behavior when communicating with diverse cultures, internal, and external
0	Communicate organizational mission, vision, objectives, and priorities
0	Prepare and deliver business communications, including meeting agendas, presentations, business reports, and project communications plans
0	Present results of data analysis to decision makers
0	Provide and receive constructive feedback
Rating Stars (Click)	FACILITATION AND NEGOTIATION		1	2	3	4
0	Mediation, negotiation, and dispute resolution techniques
0	Team building techniques
0	Create, participate in, and lead teams
0	Facilitate group dynamics, process, meetings, and discussions
Rating Stars (Click)	LEADERSHIP		1	2	3	4
0	Leadership styles/techniques
0	Potential impacts and consequences of decision making
0	Establish a compelling organizational vision and goals
0	Hold self and others accountable for organizational goal attainment
0	Promote and manage change
0	Promote continuous organization learning/improvement
Rating Stars (Click)	HEALTHCARE SYSTEMS AND ORGANIZATIONS		1	2	3	4
0	Managed care models, structures, and environment
0	Levels of healthcare along the continuum of care
0	Evidence-based management practice
0	The interrelationships among access, quality, cost, resource allocation, accountability, and community
0	The patient experience (e.g., cultural differences, expectations)
0	Healthcare technological research and advancements
0	Organization and delivery of healthcare
0	Regulatory and administrative environment in which the organization functions
Rating Stars (Click)	EMR		1	2	3	4
0	Epic
0	Cerner
0	Eclipsys
0	McKesson
0	Meditech
0	Other Computerized System
0	Computerized Physician Order Entry
0	Bar Coding for Medication Administration
MY EXPERIENCE IS PRIMARILY IN:
Unit	No. of Years	Unit	No. of Years
BURN		POST PARTUM
CRITICAL UNIT		LABOR & DELIVERY
PACU		NEWBORN NURSERY
NEUROLOGY		LEVEL II NICU
TELEMETRY		LEVEL III NICU
MEDICAL		PICU
SURGICAL		PEDIATRICS
ONCOLOGY		OB/GYN
ORTHOPEDICS		PSYCHIATRY
OPERATING ROOM		RRT
EMERGENCY ROOM		CRT
TRAUMA CENTER LEVEL 1
COMMUNITY ER
RURAL ER
Rating Stars (Click)	Age Specific Competencies		1	2	3	4
0	Infant (Birth - 1 year)
0	Preschooler (ages 2-5 years)
0	Childhood (ages 6-12 years)
0	Adolescents (ages 13-21 years)
0	Young Adults (ages 22-39 years)
0	Adults (ages 40-64 years)
0	Older Adults (ages 65-79 years)
0	Elderly (ages 80+ years)
Rating Stars (Click)	BUSINESS SKILLS AND KNOWLEDGE		1	2	3	4
0	Ability to analyze and evaluate information to support a decision or recommendation
0	Collect and analyze data from internal and external sources relevant to each situation
0	Techniques for business plan development, implementation, and assessment
0	The functions of organizational policies and procedures
0	Promote and apply problem-solving philosophies
0	Demonstrate critical thinking and analysis
0	Systems thinking
0	Facilities planning